world bank documentdocuments1.worldbank.org/curated/en/801981604636669765/...a case study review of...

SOCIAL PROTECTION & JOBS

No. 2007 | OCTOBER 2020

DISCUSSION PAPER

Boosting the Benefits of Cash Transfer Programs during the Early Years:

A Case Study Review of Accompanying Measures

Laura Rawlings, Julieta Trias, and Emma Willenborg

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Boosting the Benefits of Cash Transfer Programs During the Early Years: A Case Study Review of Accompanying Measures

Laura Rawlings, Julieta Trias, and Emma Willenborg

Using a case study approach, this comparative review examines the operational arrangements of child-focused accompanying measures in nutrition and parenting from 19 cash transfer programs. It covers both family-focused cash transfer programs for households with children, and public works programs that have incorporated accompanying measures largely in response to the need for childcare among beneficiaries. The accompanying measures reviewed include: incentives for pregnant women, parents and caregivers to use available supply-side services; the direct provision of child focused goods and services as part of the cash transfer program; and behavioral interventions for parents and caregivers to build knowledge and inform choices and parenting practices. As context for the operational case study approach, the note includes a theory of change and brief review of the available evidence on cash transfer programs’ impact on young children’s development. The note also provides a set of operational lessons learned and a ‘forward look’ to inform program design and future research.

JEL Codes: JEL classification: D1, I3, J13, O15

Keywords: Cash transfer, public works, early childhood development, accompanying measures, parenting, childcare, nutrition, psychosocial stimulation

ACKNOWLEDGMENTS This note was prepared with support from the Investing in the Early Years (IEY) Initiative and Social Safety Net Global Solutions Group (GSG). The team is grateful to the detailed and thoughtful feedback provided by Margaret Grosh, Hana Brixi, Loli Arribas-Banos, Melissa Kelly, Melissa Zumaeta Aurazo, Bénédicte Leroy De La Briere, and Anne Hilger. Saheel Chodavadia provided invaluable research support. We are also grateful to the contributions and comments for country case studies provided by Pablo Acosta, Mahamane Maliki Amadou, Melissa Zumaeta Aurazo, Barbara Barbosa, Hugo Brousset Chaman, Claudia Baddini Curralero, Emanuela Galasso, Maria Concepcion Steta Gandara, Pablo Gottret, Rebekka Grun, Camilla Holmemo, Stanislas Honkuy, Aylin Isik-Dikmelik, Philippe Leite, Iftikhar Malik, Sophie Naudeau, Carlo del Ninno, Clemente Avila Parra, Aneeka Rahman, Julia Rachel Ravelosoa, Veronica Silva, Changqing Sun, and Silas Udahemuka.

Table of Contents

Introduction ...................................................................................................................................... 3

Evidence on Cash Transfers and Child Welfare ................................................................................... 4

Theory of Change .............................................................................................................................. 5

Methodology .................................................................................................................................... 7

Case Study Comparative Review ........................................................................................................ 8

Health and nutrition-focused accompanying measures of cash transfer programs ........................................9

Parenting-focused accompanying measures of cash transfer programs ...................................................... 13

Accompanying Measures of Public Works Programs .................................................................................. 16

Lessons Learned and a Forward Look ............................................................................................... 19

Conclusions ..................................................................................................................................... 23

Bibliography ................................................................................................................................... 24

Annex: Detailed Case Studies .......................................................................................................... 27

Nutrition-Focused Accompanying Measures of Cash Transfer Programs ..................................................... 28 Bangladesh: Scaling up a successful pilot to improve nutrition outcomes for the poor .................................................. 28 Indonesia: Nutrition-sensitive family sessions improve nutrition outcomes and reduce stunting .................................. 30 Mali: Integrated intervention of cash transfers, accompanying measures, and nutrition packages ............................... 32 Nigeria: Enhanced knowledge and behavior change reduce stunting and child illness in northern Nigeria ................... 34 Senegal: Linking cash transfers and a nutrition communications campaign to a national platform ................................ 36 Yemen: Nutrition-sensitive cash transfers address child malnutrition in fragile and conflict setting .............................. 38

Parenting-Focused Accompanying Measures of Cash Transfer Programs .................................................... 40 Brazil: Largest home visiting program promotes parenting practices and nurturing care ............................................... 40 Burkina Faso: Social and behavior change communication enhances parenting practices ............................................. 43 Colombia: Mother leaders deliver psychosocial and nutritional accompanying measures ............................................. 45 Madagascar: Behavioral nudges increase parental investment in the early years .......................................................... 47 Mexico: Integrated programs enhance early stimulation, parenting, timely detection and care .................................... 49 Program 1: Promotion and Care of Child Development (PRADI) ...................................................................................... 49 Program 2: Educacion Inicial (EI) ....................................................................................................................................... 50 Niger: Incorporating psycho-social stimulation in response to household needs ............................................................ 52 Peru: A home visiting service in poor, rural and marginalized communities ................................................................... 54

Accompanying Measures of Public Works Programs .................................................................................. 56 Burkina Faso: A pioneer in mobile creche implementation at public works sites ............................................................ 56 Cameroon: A mobile creche pilot with childcare provision and parental education ....................................................... 58 Djibouti: Integrated public works and nutrition interventions focus on participation of women ................................... 60 Madagascar: Applying ECD best practices from a cash transfer program to a public works program ............................ 62 Rwanda: Introducing home-based early childhood development as a separate public works component .................... 64

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Introduction

Cash transfer programs are often designed with a dual objective: to address present poverty by relieving budget constraints which limit households’ ability to meet basic needs, and to address the inter-generational transmission of poverty by supporting investments in household members’ human capital. This longer-term objective is often pursued through ‘accompanying measures’ delivered in tandem with the income support. Accompanying measures encompass incentives to utilize available supply-side services notably in health and education, the direct provision of goods and services, and the use of information and behavioral interventions to build capacity and inform choices.

The use of accompanying measures to foster investments in children’s human capital has been a staple of traditional family-focused cash transfer programs, with a more recent evolution toward supporting children’s development in their earliest years of life. This focus reflects the growing scientific and economic evidence on the importance of early years investments for future productivity, as well as the evidence on cash transfer programs’ contributions to children’s human capital outcomes.

This note utilizes a case study approach to review the operational arrangements of child-focused accompanying measures in nutrition and parenting from 19 program case studies worldwide. The objective is to provide a useful reference on operational design features as a complement to the existing literature on the evidence and role of cash transfers in improving child outcomes. The use of case studies provides a program-specific review of the design, implementation, and evaluation of accompanying measures. The 19 case studies are a purposive sample covering a range of countries, cash transfer programs and accompanying measures. All the programs selected have an early years focus, with operational information available, and most have either ongoing or completed impact evaluations. Each case was selected to highlight a specific accompanying measure, however, many of the programs use other accompanying measures and pursue a broader range of objectives beyond those covered in this review. The cases provide a snapshot as of June 2020, but this snapshot is rapidly evolving as programs adapt to changing demands, notably in response to COVID-19, and incorporate lessons from evaluations and operational experience.

The selected accompanying measure case studies fall under two types of cash transfer programs: family-focused cash transfers that target households with children, and public works programs that have incorporated accompanying measures largely in response to the need for childcare among beneficiaries, particularly women. Family-focused cash transfer programs typically target poor and vulnerable families with children, pregnant and lactating mothers, and caregivers of young children, and therefore have an explicit human capital or child development focus. The types of accompanying measures linked to traditional cash transfer programs are designed to contribute directly to child development outcomes through nutrition, hygiene, health, child stimulation, and/or positive parenting. These categories of accompanying measures are drawn from the theoretical framework presented in a preceding paper by Arriagada et al. (2018) that examined the potential to combine cash transfer and parenting programs focused on child stimulation to boost child development, particularly for children ages 0-3 years.

Public works programs, on the other hand, have a very distinct goal of creating employment and increasing incomes for targeted households. Accordingly, these programs have not traditionally had a child development focus. This situation is changing, however, mainly as a result of the pressure on public works programs to pay more attention to gender issues and to the provision of employment opportunities for women. Correspondingly,

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the accompanying measures of public works programs have focused primarily on childcare provision for public works participants and programs increasingly reflect more robust elements to ensure childcare quality. However, several programs included in the review are incorporating measures that address a broader range of early years domains including parenting and child stimulation as well as nutrition, health and hygiene.

This note contributes to the cash plus agenda by providing a detailed comparative review of a wide range of early years focused accompanying measures. The review incorporates accompanying measures of five public works programs, which have not yet been explored in depth in cash plus literature. The comparative review contributes to a number of operational lessons learned as well as a ‘forward look’ that explores key areas for further analysis and evaluation.

The note is structured into four main sections which precede the detailed case studies. First, the note briefly reviews the evidence of the impacts of cash transfer programs on child wellbeing to establish the motivation for analyzing how accompanying measures can be used to further boost the benefits of cash on child health and development. The theory of change for categorizing the different types of accompanying measures builds on Arriagada et al. (2018) with elements of both delivery and content. Following a discussion of methodology, the case study comparative review aims to guide the reader through three categories of case studies: (1) nutrition-focused accompanying measures and (2) parenting-focused accompanying measures of traditional cash transfer programs; and (3) the growing number of accompanying measures (primarily focused on childcare) of public works programs. Finally, a set of operational lessons learned, a ‘forward look’, and brief conclusions are presented to inform program design and research. The detailed case studies provide information for each program including program content, service delivery, institutional coordination, and impact evaluation. A brief list of references and resources are included at the end of each case study to provide readers with additional information as needed.

Evidence on Cash Transfers and Child Welfare

Cash transfer programs have proven to be effective in enhancing child welfare by reducing poverty, increasing consumption, and expanding the use of preventive health services, and in some cases have improved cognitive and non-cognitive skills, nutrition, and health of young children (de Walque et al. 2017, Bastagli et al. 2016, Grosh et al. 2018). A stable flow of cash transfers can drive sustained benefits for children’s human capital, leading to transformative effects on household resources, time use, and household stress by allowing household members – particularly women – to invest in household well-being and nurturing care. For example, in Indonesia, the conditional cash transfer (CCT) program, Program Keluarga Harapan (PKH) significantly increased use of maternal and child health services, reduced stunting among young children, and increased school enrollment and completion over time (Cahyadi et al. 2018).

Similarly, emerging evidence on public works show they can improve health and nutrition outcomes and reduce household reliance on negative coping mechanisms (Dasgupta, 2013). Certain programs, such as the Productive Safety Net Program (PSNP) in Ethiopia or the National Rural Employment Guarantee Scheme (NREGS) in India, have been found to protect children’s human capital by providing an extra source of income to households and a buffer against shocks (Debela et al. 2014, Behrman et al. 2017, Mani et al. 2019, Balakrishnan 2015).

A distinctive difference of public works programs is the focus on increasing maternal labor supply rather than improving children outcomes. Public works programs may reduce household time available for adequate care and contribute to lower child nutrition, health and development outcomes, particularly when affordable and

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quality care substitutes are lacking. Maternal time plays an important role as many investments in children are time intensive (breastfeeding, visiting the health center, providing stimulation, etc.). A recent study on the NREGS in India found that maternal employment in the program had negative impacts on newborn infant survival due to the reduced maternal time spent caring for and nurturing young children (Chari et al. 2019). As public works programs have a primary objective to increase employment and earnings for working age members of poor and vulnerable households, secondary impacts on children outcomes typically fall outside the scope of stated program objectives.

For both family-focused cash transfer and public works programs, the provision of cash alone can sometimes fall short in improving human capital outcomes for young children. Cash alone might be insufficient to prompt behavior change that translates into improved outcomes for child health, nutrition and development. For instance, when comparing the relative effectiveness of conditional and unconditional cash transfers, some conditional cash transfers (CCTs) have been found to produce better human capital outcomes than unconditional cash transfers (UCTs) in the short term, and the effects of UCTs can dissipate in the long run (Özler et al. 2019). However, this is not always the case – UCTs that focus on health and nutrition of young children have been found to significantly reduce the prevalence of stunting which has meaningful implications for longer-term human development (Aguero et al., 2006).

Combining cash transfers with behavioral interventions can enhance the impact of cash transfer programs on children outcomes. In Colombia, Mexico and Peru linking parenting programs for child stimulation with the cash transfers improved child cognitive outcomes in the short term (see Arriagada et al., 2018 for a review of the evidence). Accompanying measures that focus on pregnant women, caregivers, and mothers with young children during the first 1,000 days capitalize on a window of opportunity to promote physical growth and child development. In Nigeria, providing information and conducting home visits to promote improved practices for pregnancy, childcare, and nutrition – particularly infant feeding – alongside a cash transfer program improved dietary diversity and reduced stunting and child illness (Carneiro et al., 2019). In a number of the cases reviewed here, accompanying measures were found to improve child development outcomes above and beyond the impacts of cash alone.

Theory of Change

Cash transfers can affect young child outcomes through several pathways. Family focused cash transfer programs and public works programs enable poor families to spend more on goods (nutritious food, clean water, medicine, toys, books and so on) and services (health care, education, and childcare). Both can also reduce the pressures of financial strain and deprivation, improving psychological wellbeing for the family as well as parental ability to provide more nurturing care. Cash transfers have greater impacts among poor or vulnerable groups and are an effective mechanism to reach children and families most at-risk for human capital deficits. While cash transfer can allow parents to invest in time-intensive activities for children (breastfeeding, attend to health visits, playing with children, etc.), public works programs might reduce maternal time available for those investments, creating a risk of reducing the positive impact of the income support on children outcomes. Figure 1 presents the theory of change on how cash transfers and public works programs can affect children outcomes.

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Figure 1: Theory of Change for Cash Plus Programs

Source: adapted from Arriagada el al 2018

Accompanying measures promote investments in children’s human capital through three primary channels:

1) Incentives for pregnant women, parents and caregivers to use available supply-side services for health,nutrition, early education, and childcare, such as requirements for preschool attendance or growthmonitoring.

2) The direct provision of child focused goods and services as part of the cash transfer program. Thisapproach is often used when supply-side services in health, nutrition and/or education are in limitedsupply or of poor quality. In the case of public works, mobile childcare can be used to address challengeson take up of the program.

3) Behavioral interventions including ‘nudges’, information or training for parents and caregivers topromote behavior change, address information asymmetries and build skills. Social and behavior changecommunication strategies (SBCC) aim to build knowledge and awareness of parents and caregivers topromote their children’s nutrition, physical health, cognitive and non-cognitive skills and provide themwith a safe and stimulating environment for early learning and development.

Through these three channels, accompanying measures aim to change parental behaviors and practices to ultimately influence child outcomes. The evidence suggests that accompanying measures can be effective at reaching parents and caregivers with information on how to improve their child’s development and encouraging the use of relevant services. Translating behavior change into sustained improvements in outcomes often presents additional challenges given the multitude of factors that influence a young child’s development. However, an emerging evidence base is showing that when combined with cash transfer or public works programs, accompanying measures have potential to lead to improved outcomes for children. The operational components that contribute to greater quality and effectiveness of ‘cash plus’ programs are explored further in this note.

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Methodology

The 19 case studies included in this review cover cash transfer and public works programs’ use of accompanying measures focused on the early years. The case studies were selected based on a purposive sampling of programs that have operational information available, including both publicly available information as well as operational documents provided directly by World Bank country teams. Only programs with substantive information available on the key elements for review were included, including details related to program content, curriculum, service delivery, and institutional coordination. World Bank teams in the countries of interest were contacted directly to provide relevant operational information. This was supplemented by researching publicly available information, particularly for published impact evaluations which include further details on program implementation as well as results. A number of programs were excluded or removed due to the lack of available information, or a limited focus on early years outcomes. Most of the selected case studies have ongoing or completed impact evaluations in order to highlight programs that contribute to the growing evidence base on accompanying measures during the early years. Accompanying measures of public works programs are less common, and case selection was based entirely on outreach to World Bank teams known to be implementing these types of programs. Therefore, the sample can be considered illustrative yet purposive in order to provide readers with a useful overview of the types of early years focused accompanying measures linked to cash transfer and public works programs.

Each case was selected to highlight a particular accompanying measure, however, many of the programs use other accompanying measures and pursue a broader range of objectives beyond those covered in this brief review. The only exception is Mexico, which had two unique accompanying measures with operational information available: PRADI, which was an existing component of the PROSPERA cash transfer program; and “Initial Education” which was added to the CCT in areas with limited access to early learning opportunities and makes a valuable contribution to the evidence base through an impact evaluation.

The case studies are organized by type of social protection program (cash transfer and public works), and category of accompanying measure. We have considered two broad categories of accompanying measures for ease of navigating the cases:

1) Health and Nutrition Accompanying Measures. This includes (1) incentives to utilize maternal and child health and nutrition services (e.g. pre- and post-natal care, immunization, preventive health services, growth promotion and monitoring); (2) direct provision of health and nutrition services, as well as provision of child-focused goods through nutrient fortification, supplements, or nutritional packages; and (3) behavioral interventions including information, counseling and training on: dietary diversity and healthy nutrition practices (e.g. exclusive breastfeeding, complementary feeding, infant and young child feeding), handwashing and improved sanitation to reduce child diarrhea, and proper care practices to promote child health and seek out health services as needed.

2) Parenting Accompanying Measures for Child Stimulation. Parenting programs are behavioral interventions aimed at enhancing parent-child interactions and the knowledge, beliefs, attitudes and practices on child stimulation. The aim of the program is to equip parents with skills to promote cognitive, language, motor and socio-emotional skills in young children. Parenting interventions on child stimulation are by nature cross-disciplinary and often go beyond child stimulation including aspects of proper nutrition, health, hygiene and protection reflected above.

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The case studies are broken down into three groups as follows for both the case study snapshot, as well as the detailed case study review:

1. Health and nutrition-focused accompanying measures of cash transfer programs (6 cases): Bangladesh, Indonesia, Mali, Nigeria, Senegal, and Yemen.

2. Parenting-focused accompanying measures (that focus on promoting child stimulation) of cash transfer programs (8 cases): Brazil, Burkina Faso, Colombia, Madagascar, Mexico (two programs), Niger, and Peru.

3. Accompanying measures of public works programs (5 cases): Burkina Faso, Cameroon, Djibouti, Madagascar, and Rwanda.

Each country and program context, as presented in the detailed case studies, informs the design and implementation of the selected accompanying measures. First, we present a comparative overview of the key elements to consider within each of the three groups of case studies, which is followed by the detailed case studies themselves. Each of the detailed case studies is structured as a short overview including the country background, a summary of the accompanying measure, and key elements of program content, service delivery, institutional coordination, and impact evaluation.

Case Study Comparative Review

This section provides a comparative overview of key elements of the 19 cases. This section reflects broad elements of the various cases, whereas the detailed case studies provide additional program details and include resources and references available with more information. The three groups of cases are discussed according to the following six elements:1

1. Target population: The group of individuals or households that are reached by the accompanying measure, which includes all or a segment of cash transfer or public works program beneficiaries. For most programs, the target population includes pregnant and lactating women, and mothers of children under two, five, or six years of age. Some accompanying measures also reach members of the broader community beyond the direct cash transfer beneficiaries.

2. Delivery Modality and Frequency: The method for delivering the accompanying measures, whether through regular sessions with a small group of beneficiaries, or individual home and/or health clinic visits. Many programs utilize both methods or incorporate alternative ways of reaching beneficiaries with key messages, products and services (e.g. mass media, community meetings, etc.). Group sessions are typically held on a monthly basis, and home and health clinic visits either monthly or as needed.

3. Topics: The content covered by the accompanying measures, either focused on health and nutrition, or parenting and child stimulation. In many cases, both are covered. Topics often include those covered in UNICEF’s Key Family Practices (KFP), or other priority areas identified by WHO, UNICEF, Scaling Up Nutrition (SUN), and others.

4. Curriculum: The approach used to organize and deliver the key topics identified. Most countries utilize international best practice and adapt messaging and content based on the local context, priorities, and

1 For an extended description of design features of parenting programs see Arriagada et al 2018.

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norms. International curricula include Reach Up, Care for Child Development, and Learning Through Play. More description on the curricula is provided in Arriagada et al 2018.

5. Social and behavior change communication (SBCC) strategies: Strategies used to build knowledge and awareness among parents and caregivers to support their children’s health and development, such as group-based discussions; opportunities for performance-based activities (play, demonstrations, etc.) with feedback to parents; problem-solving or planning to reduce barriers to behavior change; social support from peers, community, and authorities (peer-to-peer); materials including home-made toys and books; and media such as songs, pictures, posters, SMS messaging, or automated calls.

6. Frontline Workers: The individuals responsible for delivering the accompanying measures to beneficiary households and for connecting beneficiaries with relevant early childhood services. Frontline workers conduct the group-based sessions and home visits and provide referrals as needed. Depending on the program, they may be paid a salary, receive a stipend or cash transfer, or be entirely voluntary; and professional (e.g. NGO or program staff) or community-based (e.g. community volunteers, facilitators, or educators, and sometimes called mother leaders).

Finally, the comparative tables include a brief overview of the impacts of the selected accompanying measure on child development outcomes based on completed or ongoing impact evaluations. These impacts are not analyzed in detail but instead help to provide insight into the key areas of child development that can be influenced by different types of interventions. Further information, including references, on the impact evaluations for each case can be found in the detailed case studies.

Health and nutrition-focused accompanying measures of cash transfer programs

Details of the six programs with health and nutrition-focused accompanying measures are presented in Table 1. These include accompanying measures linked to family-focused cash transfer programs in Bangladesh, Indonesia, Mali, Nigeria, Senegal, and Yemen. The key elements of these programs are discussed briefly below.

Target Population. Health and nutrition-focused accompanying measures are tailored to the needs of pregnant women, lactating mothers, and parents and caretakers of young children. In Bangladesh, Mali, Senegal, and Yemen, accompanying measures focus on children under five, whereas Nigeria focuses on children under two (the first 1,000 days). In Indonesia, children are reached through the age of six. The focus age group varies slightly depending on government priorities as well as the health and development needs of mothers and young children within each context. The group meetings in Mali were open to all members of the broader community, rather than only beneficiaries. While it can be difficult to identify and reach pregnant women, all programs do prioritize the importance of reaching women as early as pregnancy to promote maternal health and nutrition including support for the recommended level of antenatal care, healthy childbearing, and postnatal care.

Delivery Modality and Frequency. Nearly all health and nutrition-focused accompanying measures are delivered through a combination of community-based group sessions and individual health center visits or home visits. All programs include group sessions that cover a variety of health and nutrition-related topics, typically held on a monthly basis for 20-25 beneficiaries and 1-2 hours per session. These activities may be complemented by health care visits conducted at existing health facilities in order to incentivize the use of existing health and nutrition services. In Bangladesh, Indonesia, and Senegal, beneficiaries are encouraged to attend regular health clinic visits for pre- and post-natal care for pregnant women and mothers, and growth monitoring and promotion for young

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children. In Nigeria and Yemen – areas affected by instability and conflict – home visits are conducted instead, with additional counseling and referrals to health centers provided as needed. In Yemen, the program transitioned from group sessions to home visits in order to reduce exposure to conflict. Home visits allow frontline workers to reach the target population directly given the potential lack of regular and safe access to adequate healthcare services. Mali is the only program to directly provide a Preventive Nutrition Package (PNP) to the most vulnerable groups. In addition to the combination of group-based and individual sessions, programs in Nigeria and Senegal involve larger-scale media efforts to reach the broader community with nutrition messaging, through radio, posters, SMS and calls, community assemblies, and meetings with local authorities.

Topics. The focus on health and nutrition is motivated by high levels of maternal and child malnutrition and poor health outcomes. Stunting prevalence among children under five is high, reaching 36 percent in Bangladesh, 28 percent in Indonesia, and 27 percent in Mali. In Nigeria, the program focuses on the north where stunting reaches 70 percent. The high prevalence of malnutrition, as reflected by high levels of stunting, wasting and underweight, is reflective of a combination of factors including insufficient knowledge, behaviors, and practices regarding dietary diversity, sanitation and hygiene, and infant and young child feeding. The content, delivered on a monthly basis in group-based settings, is further reinforced through home visits, individual counseling sessions, or health center visits. Each program customizes content to the local context: for example, in Bangladesh, accompanying measures focus on the linkages between child nutrition and cognitive development; whereas in Yemen they focus on the specific needs and vulnerabilities of women and children living in conflict-affected areas including hygiene and systems for malnutrition screening and referral.

Curriculum. It is common for programs to develop their own locally appropriate curriculum in a process led by the relevant government agencies (notably ministries for health, social protection, education, or those that address the needs of women and children). This is the case in Indonesia, Mali, and Senegal. Curriculum in Bangladesh includes nutrition and cognitive topics, which reflects inputs from the International Center for Diarrheal Disease Research (based in Dhaka) as well as from the Reach Up curriculum, which focuses on parenting and child stimulation. Curriculum for the program in Nigeria was spearheaded by two international NGOs (Save the Children and Action Against Hunger) but incorporated messaging from the Community Infant and Young Child Feeding (C-IYCF) guidelines developed by the Government of Nigeria. Often, curriculum development depends on the expertise and contributions of several government and non-government actors; but adapting messaging to local language, context, and norms and ensuring consistency and accuracy across programs is essential.

SBCC Strategies. All programs use a range of SBCC strategies to reinforce messaging, raise awareness, and contribute to behavior change. The most common strategies to promote improved health and nutrition behaviors are group-based discussions, feedback to parents on nutrition practices, and social support from peers (peer-to-peer). Interactive discussions are tailored to different groups of mothers or families, and reflective of age-appropriate nutrition content. Bangladesh and Indonesia use scenarios to present child development topics and promote interaction between children and parents or caregivers. Mali and Nigeria both utilize larger scale communications efforts to reach a greater population beyond only beneficiaries. Bimonthly group sessions in Mali are open to all members of the community, not only cash transfer beneficiaries. This incorporates a peer-to-peer approach in which other members of the community, including local authorities and religious leaders, are included to promote awareness and contribute to behavior change. In Nigeria, ‘low-intensity channels’ include posters, radio, religious teachings, health talks, food demonstrations, and pre-recorded SMS or voice messages help to reach all members of the community. Finally, Senegal applies innovative strategies including theater, songs, and peer-to-peer “grandmother groups” given the level of respect for older women in the community.

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Frontline Workers. Frontline workers, such as NGO workers or community educators/volunteers, facilitate the group sessions, provide referrals for health clinics, and conduct the home visits. They are typically paid a monthly stipend or salary for their activities. The pay and profile of frontline workers depends heavily on the local context and existing local services and structures. Bangladesh has a strong network of NGOs present in the intervention areas, so NGO staff make up the frontline workers and are paid monthly (approximately USD $50 per month). In Indonesia, service delivery is highly decentralized, so the program relies on locally based program facilitators to deliver accompanying measures. These individuals have significant autonomy to develop and deliver locally relevant content, and program success largely depends on the capacity and effectiveness of the local facilitators. Nigeria and Yemen rely on community volunteers and community health educators, respectively – again due to limited availability of health and nutrition service providers in conflict-affected areas – and in both cases these individuals are from the community where they work and paid a monthly stiped. Senegal relies on the existing structure under the well-established Nutrition Enhancement Program (NEP) and frontline workers include a hierarchy of nutrition aides, outreach workers, and mother leaders. Each program has a system of monitoring and supervision of frontline workers and provides some level of training and materials to build capacity.

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2 Information was delivered through two separate channels for the Nigeria program: ‘high-intensity’ included small group parenting sessions and one-on-one home visits. ‘Low intensity’ included posters, radio, health talks, food demonstrations, and pre-recorded SMS or voice messages.

Table 1. Nutrition-Focused Accompanying Measures of Cash Transfer Programs

Country Target Population

Delivery Modality and Frequency Topics Curriculum SBCC

Strategies Frontline Workers Impacts Group-

based Individual

visits Other

Bangladesh

Pregnant women,

mothers of children under 5

Monthly Health

clinic visits; Monthly

-- Child nutrition,

cognitive development

International Center for Diarrheal Disease

Research; Reach Up

Discussions, Feedback to

Parents, Play, Scenarios, Materials

NGO Staff: Literacy required

Paid monthly

Increased maternal knowledge, food

consumption; reduced wasting** ª

(Ferre and Sharif, 2014)

Indonesia

Pregnant women,


Monthly

Health clinic visits

and referrals; Monthly

-- Maternal and

child health and nutrition

Government of Indonesia;

support from WB and UNICEF



Program Facilitators:

Diploma required Paid monthly

Improved MCH behaviors, food consumption; reduced

stunting** (Cahyadi et al. 2018)

Mali

Pregnant women,


Twice per month

(open to all)

--

Preventive Nutrition

Packages (PNP)

Maternal and child health and nutrition, family

planning, hygiene

Government of Mali; NGO staff

and doctors adapt to local

context

Peer-to-Peer, Information on Payday, Media

NGO Staff: Paid monthly

Increased food consumption, dietary diversity; PNP

reduced child undernutrition** (Hidrobo et

al., 2019)

Nigeria2

Pregnant women,


Monthly (‘high

intensity’)

Home visits (‘high

intensity’)

Radio, posters,

SMS (‘low intensity’)

Pregnancy, childcare,

nutrition, and infant feeding

practices

Save the Children and

Action Against Hunger; aligned with Government IYCF messaging

Discussions, Peer-to-Peer,

Media, Demonstrations

Community Volunteers:

Literacy required Paid monthly

Improved MCH knowledge and behaviors, dietary

diversity; reduced stunting, child illness*

(Carneiro et al., 2019)

Senegal

Pregnant women,


Monthly


and counseling; as needed

Village assembly;

Local authority meetings

Maternal and child health and

nutrition, access to ECD

and health services

Government of Senegal (NEP

structures), support from

UNICEF

Discussions, Play, Feedback

to Parents, Peer-to-Peer, Grandmother

Groups

Nutrition Enhancement

Program (NEP) (nutrition aides,

outreach workers, mother leaders)

Increased dietary diversity, food consumption,

vaccination; reduced diarrheal disease**

(Sall et al., 2012)

Yemen

Pregnant women,


Monthly; with

additional Quarterly sessions

Home visits and

health center

referrals; as needed

Malnutrition

screenings

Infant and young child

nutrition, health, and hygiene

“Cash for Nutrition” program

curriculum


Parents, Peer-to-Peer

Community Health Educators:

Diploma required; Monthly stipend

Increased maternal nutrition knowledge and practices,

dietary diversity; decreased malnutrition; reduced stunting and wasting*

(Kurdi et al., 2019) Sources: compiled by authors based on the detailed case studies. *Indicates impact of the accompanying measure only (impact evaluation measured differentiated impacts of the accompanying measure, above and beyond the cash transfer) **Indicates combined impact of the accompanying measure and cash transfer (impact evaluation did not differentiate between impacts of accompanying measure and cash transfer) ª Indicates the reported results are from a previous variation of the program.

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Parenting-focused accompanying measures of cash transfer programs

Details of the eight programs with parenting-focused accompanying measures, notably for early childhood stimulation, are presented in Table 2. These include accompanying measures linked to family-focused cash transfer programs in Brazil, Burkina Faso, Colombia, Madagascar, Mexico (two programs, PRADI and EI), Niger, and Peru. The key elements of these programs are discussed briefly below. While nutrition-focused accompanying measures also include efforts to engage parents, this group of case studies focuses on parenting to promote child stimulation.

Target Population. Similar to the nutrition accompanying measures, the target population of parenting-focused accompanying measures includes households with children under the age of 6. The target age range does vary slightly between programs: under 3 in Brazil, Colombia, Mexico (PRADI and EI), and Peru; under 5 in Burkina Faso, Niger, and; and under 6 in Madagascar and. Furthermore, pregnant women are sometimes also included in the program. Reaching women before birth for the necessary prenatal visits and health and nutrition messaging is a priority for nutrition-focused accompanying measures, whereas parenting-focused accompanying measures focus on interventions after birth and the relationship between young children and caregivers, targeting pregnant women with the aim to ensure the services will start once the baby is born. However, several of the programs do aim to enroll pregnant women, so that they are able to begin participating with age-appropriate activities as soon as they give birth.

Delivery Modality and Frequency. Parenting accompanying measures are delivered through community-based group sessions, home visits or some combination of these. Group meetings or a combination of group meetings and home visits are more frequently used. Only Brazil, Colombia and Niger implement the program primarily through home visits; whereas Madagascar and Mexico (EI) implement primarily through group-based sessions. The program in Burkina Faso also uses home visits as the primary delivery modality, but regular group-based sessions are used to reinforce messages delivered in the home visits in a setting of 25-30 beneficiaries. Peru and Mexico (PRADI) instead use home visits as the primary mechanism to reach families, and then hold group sessions to reinforce and practice what is learned during the home visits. In Burkina Faso and Niger, village assemblies are also convened on a monthly basis for both beneficiaries and non-beneficiaries in order to provide community support for behavior change and to raise awareness among influential community members. In terms of the dosage, weekly sessions are more common followed by monthly sessions.

In terms of effectiveness, there is little experimental evidence to guide choices across these delivery modalities. Preliminary results from an experiment in Guatemala comparing the effectiveness of group meetings and home visits show that while both modalities can achieve positive outcomes particularly when implemented with high intensity, group meetings are more cost effective overall (Trias et al. 2020). Additionally, a review that compares 10 studies using the home visit modality with seven studies that combined home visits and group meeting (Aboud et al. 2015) suggests that the combination of delivery modalities had a better impact on child development than either one individually. But the evidence is still limited to reach general conclusions, and further considerations in selecting between models are discussed in Arriagada et al. 2018.

Topics. The programs aim to promote effective parenting practices that support positive child development, and all of them encompass a holistic approach that integrates parenting, child stimulation, health, and nutrition in some degree. Certain programs focus on improving parenting practices for nutrition, particularly in Niger, Madagascar, and Burkina Faso, where malnutrition is a significant barrier to child development. These programs

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also incorporate core elements of child stimulation and psycho-social development, strengthening the child-caregiver relationship. In Colombia, persistent gaps in cognitive and linguistic development between children from different socioeconomic groups contributed to the program design centered around psycho-social development and supporting mother-child interactions in poor communities. Mexico (EI) took a similar approach by focusing on poor and isolated communities that lack access to quality preschool services. The program in Peru is structured around three topic areas: ‘family life’, ‘learning through play’, and ‘tell me a story’ in order to promote linguistic, motor, and cognitive development. Therefore, the content covered reflects both the gaps in child health and development as well as the availability of services within each country context.

Curriculum. Parenting programs are frequently adapted from the Care for Child Development model (developed by UNICEF/WHO) and the Reach Up curriculum. The Reach Up provides structured, age-specific content to guide front-line workers on each visit, whereas the Care for Child Development package provides general guidelines on the content and is accompanied by a training package for frontline workers. Peru and Colombia have adapted curriculum based on Reach Up, and Brazil based the home visiting approach on Care for Child Development. Burkina Faso, Madagascar, and Niger incorporated topics from the UNICEF Key Family Practices into context-specific curricula, which also reflects the focus on parenting to promote improved health, hygiene and nutrition practices. Only the cases from Mexico (PRADI and EI) were exclusively developed by the country based on local expertise.

SBCC Strategies. Similar to nutrition-focused measures, the parenting programs make use of multiple social and behavior change communication (SBCC) strategies to improve parental behavior. Commonly, these include discussions during group sessions surrounding relevant child development topics, demonstrations of play and child-caregiver interactions with feedback to parents and use of locally made toys and early learning materials. In Madagascar, payday ‘nudges’ are used to deliver messages to mothers about self-affirmation and financial planning. Both the EI and PRADI programs in Mexico highlight the role of fathers in supporting positive parenting practices. The intensive home visiting model in Brazil provides an opportunity to directly coach parents on reducing stress and showing affection for their children, using locally available materials and by modelling positive play behavior to promote parental engagement. Village assemblies in Burkina Faso and Niger highlight the importance of local authorities and elders in raising awareness and support behavioral change.

Frontline Workers. Similar to the nutrition accompanying measures, frontline workers lead the group sessions and conduct home visits, but their profiles and backgrounds vary. Community facilitators in Burkina Faso and Mother Leaders in Madagascar require no minimum level of education and are voluntary positions (in Madagascar, Mother Leaders are cash transfer beneficiaries so receive the regular transfer amount, but no additional payment for their services). In Niger, community educators have no minimum level of education but receive a monthly stipend. Brazil, Mexico (PRADI), and Peru all require frontline workers to have some level of expertise or experience working with children, such as trained social workers in Brazil, education and two years of relevant work experience in Mexico, and experience with children in Peru. On the other hand, Mother Leaders in Colombia and Promotoras in Mexico (EI) are required to have basic literacy.

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Table 2. Parenting-Focused Accompanying Measures of Cash Transfer Programs


Delivery Modality Topics Curriculum SBCC

Strategies Front-line Workers Impacts Group-

based Individual

visits Other

Brazil Poor

households with children

under 3

-- Home visits; Monthly then weekly (after

birth)

--

Parenting practices, early stimulation,

motor and cognitive development

Care for Child

Development

Demonstrations, Play, Feedback

to Parents, Materials

Trained social workers, including students

Evaluation in progress

Burkina Faso

Pregnant women,


Monthly Home Visits; Weekly

Village assembly; Monthly

Parenting to promote nutrition, child health, and

psycho-social development

UNICEF KFP, SUN, Learning

Through Play

Discussions, Demonstrations, Play, Feedback

to Parents, Peer-to-Peer

Community Facilitators: No minimum education; Voluntary


Colombia Mothers of

children under 3

-- Home visits; Weekly

Nutrition Suppleme

nt

Psychosocial stimulation, nutrition,

mother-child interaction

Adapted from Reach Up,

with nutrition component


to parents, Materials

Mother Leaders: Basic

reading comprehension; Monthly stipend

Increased parental investment; improved cognitive and

language outcomes in the short term but not sustained in

medium term* (Attanasio 2014; Andrew 2018)

Madagascar Mothers of

children under 6

Monthly -- Pay-day ‘Nudges’

Parenting practices, child development,

self-affirmation, financial planning

UNICEF KFP; WB and

ideas42 behavioral elements


to Parents, Payday Nudges

Mother Leaders:

No minimum education; Voluntary

Grade advancement, uptake of parenting behaviors, improved child language and cognitive

skills; reduced food insecurity* (World Bank 2018)

Mexico (PRADI)

Families with children

under 3 Monthly

Early detection,

referral, links to services; as needed

-- Child-rearing

practices, detection and timely care

Own; community

workers trained to facilitate

Demonstrations, Feedback to

Parents, Peer-to-Peer, Father

Inclusion

Education in field of practice;

2 years’ work on child health

Improved preventive care and health outcomes, number of

health visits for children under 5** (Parker et al. 2017)

Mexico (EI)

Pregnant women and caregivers of children

under 3

Weekly -- --

Parenting practices, support to child-

caregiver relationship

Developed by team of Mexican

specialists


Parents, Peer-to-Peer, Materials

Promotoras: Primary

education (for basic literacy);

Voluntary

Improved child cognitive skills, especially in indigenous communities and lowest

quintile of child development* (Fernald et al., 2017a)

Niger Poor

women with children under 3

Monthly Home visits; Monthly

Village assembly

Parenting for health, nutrition, hygiene, family planning, psycho-social development

Adapted from UNICEF KFP

Feedback to Parents, Media,

Peer-to-Peer

Community educators:

No minimum education;

monthly stipend

Improved parenting practices, child socio-emotional skills; reduced harsh discipline*

(Premand et al., 2020)

Peru

Pregnant women,


Twice per

month

Home visits; weekly --

‘Family life’, ‘Learning through play’, ‘Tell me a

story’

Adapted from Reach Up

Play, Feedback to Parents

Facilitadoras: Literacy, work with children;

Monthly stipend

Improved cognitive and language development,

problem solving, communications skills* (Araujo

et al., 2018) Sources: compiled by authors based on the detailed case studies. *Indicates impact of the accompanying measure only (impact evaluation measured differentiated impacts of the accompanying measure, above and beyond the cash transfer) **Indicates combined impact of the accompanying measure and cash transfer (impact evaluation did not differentiate between impacts of accompanying measure and cash transfer)

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Accompanying Measures of Public Works Programs

There is less program experience for accompanying measures linked to public works programs that support investments in the early years. These interventions are intended to help increase female project participation while creating safe and stable places for care and an opportunity to improve child development outcomes through nurturing care, early stimulation, and health and nutrition behavior change activities. A usual concern when considering childcare services is the quality of the service. High quality childcare improves children linguistic, cognitive, motor and socio-emotional skills (Britto et al. 2017, Engle et al. 2011, Berlinski et al. 2008). By contrast, attending low quality childcare might have a negative impact on child development (Bouguen et al. 2013; Rosero and Oosterbeek 2011). The quality of child-caregiver interactions is a key determinant of such programs’ impacts, as Indonesia and Mozambique demonstrated with effective center-based preschool programs for children ages 3 to 6 (Martinez et al. 2013 and Nakajima et al 2016). These programs included minimal infrastructure investments but improved children’s cognitive abilities thanks to their interactions with well-trained caregivers. Delivering quality, center-based interventions for children under 3 is harder because they require costlier structural investments (such as lower child-to-staff ratios) (WDR 2018).

Details of the accompanying measures of public works programs are presented in Table 3. The five case studies reflect three general models: (1) mobile childcare that accompanies public works programs in Burkina Faso, Cameroon and Madagascar and follows participants with children as they move between worksites; (2) childcare as an additional workstream option for beneficiaries of the expanded public works program in Rwanda; and (3) a nutrition intervention that accompanies women’s participation in a workfare program in Djibouti. The case of Djibouti mirrors more closely the traditional ‘cash plus’ model seen for cash transfer programs. The key elements of these programs are discussed briefly below.

Target Population. In all cases, both public works participants and their young children are reached directly with the interventions. The young children of public works participants are reached through the childcare services provided at public works sites (or nearby), except in Djibouti, where the program does not include a childcare component. Mothers and caregivers who are public works participants are also reached through the monthly group-based information sessions.

Delivery Modality and Frequency. The delivery modalities include both monthly group-based sessions on topics relevant to child development, as well as childcare that is provided during public works activities. The main exception to this model is Djibouti, where the public works program does not include childcare. Instead, the accompanying measures reflects more of the traditional model with monthly nutrition-focused sessions with growth monitoring, the provision of nutritional supplements, and home visits with referrals to health services as needed. In all other cases, childcare is provided alongside the public works activities for the children of public works participants. In Rwanda, childcare is one of the public works workstreams, and so is not explicitly for the children of public works participants but rather for anyone in the community who requires childcare. The provision of childcare is largely focused on creating safe environments for young children to be cared for while their mothers work so they are not left unattended.

Topics, Curriculum, and SBCC Strategies. The topics covered in the group sessions for mothers and caregivers are very similar to those covered in the traditional nutrition and parenting accompanying measures: nutrition, health, hygiene, parenting, child stimulation, and child protection. Child protection is commonly included as a topic given the need to provide a safe environment for children while their mothers work. In Burkina Faso, the structure of the childcare component varies depending on the age of the child: sleep, play, and proper feeding for children

17

under 2; and socialization, good behavior, basic hygiene, and language and cognitive development for children 2-6. The curricula are typically developed by national government agencies to respond to the needs of female participants and their children, with inputs from international best practice. Many of the countries also have active cash transfer programs with a human development focus (see Madagascar, Burkina Faso examples above), so are able to adapt the curricula based on experience from existing nutrition- or parenting-focused accompanying measures. Lastly, the SBCC strategies used are similar to those of traditional accompanying measures, with an additional emphasis on demonstrations of play, child stimulation, and child-caregiver interactions.

Frontline Workers. The frontline workers are all beneficiaries of the public works programs who participate in the program as caretakers. They are selected from among public works participants and paid at the same daily rate. While caretakers tend to be female beneficiaries, this is not always the case. For example, in Burkina Faso, approximately 70 percent of caretakers are women whereas 30 percent are men.

Quality of childcare. Efforts to ensure childcare quality vary somewhat between programs, and in some cases are more robust than others. The most common elements for quality assurance include training and supervision of frontline workers (caretakers), established caretaker-child ratios, and standards to ensure security, hygiene, and cleanliness. Caretakers are typically trained in a range of topics related to early childhood development, health and nutrition, and how to organize and manage the creche (e.g. setting a daily schedule, proper childcare practices, and ensuring a secure and clean space). In Rwanda, each childcare center (home or community-based) is required to have one lead care-giver and six assistant caregivers, who provide care for 10-15 children in line with the country’s ECD minimum standards of teacher-child ratio for children between the ages of 2 and 6. Procedures surrounding organization of work, the childcare setting, caregiver scope of work, training requirements and supervision arrangements are specified in detail in the public works program implementation guidelines. In Madagascar, each mother leader is responsible for a maximum of six children or a maximum of three infants, and follows a set daily schedule based on topics for which they receive both training and supervision.

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Table 3. Accompanying Measures of Public Works Programs



Strategies Front-line Workers

Ensuring Quality of Childcare

Impacts Group-based Other

Burkina Faso

Children aged 0-6 of

PW participants; Caregivers

Monthly Childcare during PW activities

Mother-child interaction,

nutrition, child stimulation,

hygiene

Own; developed by education

and ECD government

agencies

Demonstration, Play,

Feedback to Parents

Brigadieres Assistantes Maternelles

(BAM); Public works

participants paid at daily PW rate

Training and, supervision of

frontline workers;

standards of cleanliness and hygiene


Cameroon




Hygiene, nutrition, early

stimulation, child protection

Own; developed by education

and ECD government

agencies

Discussion, Play,

Feedback to Parents

Female Caretakers: Public works

participants; paid at daily PW rate

No evaluation

Djibouti

PW participants;

pregnant women and mothers of

children under 2

Monthly; with

growth monitoring

Nutrition supplement; home visits (as needed)

Nutrition, feeding

practices, growth

promotion

Health staff and NGOs;

supported by Ministries of

Health and SP


Feedback to Parents

Community workers and

facilitators; paid at daily PW rate

N/A

Increased female participation, food

consumption, nutrition

behaviors** (Brodmann et al.,

2016)

Madagascar



Monthly

Childcare during PW activities; support services

Health, nutrition,

hygiene, child protection,

child stimulation

UNICEF KFP with Ministry of Education and

HDCT ECD activities


Feedback to Parents

Mother Leaders selected from among public

works participants

Caregiver-child ratios; training and

supervision of frontline workers;

standards of cleanliness and hygiene

No evaluation

Rwanda



Monthly; open to all

Regular childcare service as

PW workstream

Health, nutrition, hygiene, parenting

practices, child stimulation,

child protection

Based on national ECD

guidelines, developed by expert service

provider

Demonstration, Play, Child Interaction,

Parent Feedback

ePW caregivers; paid at daily PW

rate No evaluation

Sources: compiled by authors based on the detailed case studies. **Indicates combined impact of the accompanying measure and cash transfer (impact evaluation did not differentiate between impacts of accompanying measure and the public works program) Note: given the recency of efforts to link child-focused accompanying measures to public works programs, impacts on child development outcomes are not yet well established.

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Lessons Learned and a Forward Look Based on the comparative case study review as well as existing evidence on cash transfers and accompanying measures, we can distill a set of ‘lessons learned’ that can be applied to contribute to improved outcomes for young children. These include lessons within three key operational areas: content, service delivery, and institutional framework (Table 4). These lessons can be applied at various stages of accompanying measure design and implementation in order to enhance the impact of cash transfer programs on early years outcomes.

Table 4. Operational Lessons Learned from the Comparative Case Study Review

Content

1. Tailor content to the child’s age and stage of development as well as the local context. Consider age-appropriate nutrition and child development focused curricula that reflect social norms and incorporate culturally relevant messaging and activities.

2. Give parents opportunities for practice and use technology for support. Through practice, parents refine their caregiving skills; and facilitators can provide feedback and encouragement. Phone calls, radio, SMS and online content help to keep parents connected remotely.

3. Target caregivers, including pregnant women and fathers. Mothers, fathers, grandparents, and other caregivers are the architects of a young child’s development. Messages should address the specific needs of pregnant women and adolescent girls.

4. Consider a holistic approach that integrates nutrition and child stimulation. Young child development is interconnected and complex, and developing content, curricula, and messaging requires inputs from across sectors and stakeholders.

5. Incorporate behavioral insights into activity design. Various nudges and SBCC strategies can address barriers and facilitate learning of key content, notably through games, role playing, and small group activities keep parents interested and engaged.

Service Delivery

6. Invest in infrastructure and workforce quality. Establish service standards, including parameters for health, safety and space as well as dosage and duration. Ensuring frontline worker quality through supervision, training and incentives is equally if not more important than investing in physical materials and resources, given the role of child-caregiver interactions in promoting healthy child development.

7. Prioritize and tailor accompanying measures to the needs of vulnerable beneficiaries. Resources, enabling environments, and existing human capital deficits are often distinct among disadvantaged groups, such as minorities, rural communities, and households living in extreme poverty.

8. Balance the costs and benefits of different delivery modalities and frontline worker profiles. Program delivery via group-based sessions, individual visits, or using technology, and engaging paid or volunteer frontline workers, will have implications for program quality as well as cost.

9. Leverage behavioral elements using different delivery modalities. Group sessions can reinforce positive social norms and dynamics, whereas individual sessions allow for

20

personalized attention and feedback. Complementarities between modalities help to reinforce messaging and create feedback loops that promote behavior change.

10. Utilize technology and innovation for program delivery. Phones, radio, and internet can be used to deliver content, while phone- or computer-based systems can quickly reach frontline workers with training and supervision to increase program efficiency.

Institutional Framework

11. Invest in a monitoring and evaluation system. Systems for monitoring ensure that beneficiaries are being adequately reached with consistent and quality services; while evaluation can help identify and compare effective delivery modalities and assess outcomes.

12. Strengthen horizontal collaboration across sectors at the national and local levels. Early years efforts require mechanisms to ensure adequate leadership, supervision, and inputs from key actors in social protection, health and nutrition, and education sectors.

13. Establish mechanisms for vertical coordination and accountability. Program implementation requires communication and monitoring between actors at all stages of program delivery, from policymakers to program managers, service providers, frontline workers and beneficiaries.

14. Consider alternative models for linking accompanying measures to cash transfer programs. These include integrated, convergence, alignment, and piggybacking models, as defined and discussed in Arriagada et al., 2018.

Two key areas emerge that compel a ‘forward look’ at the use of early years focused accompanying measures. Addressing gaps in program design and practice, as well as in research and evidence, will help to build experience and knowledge in order to more effectively design and implement accompanying measures programs and contribute to improved human capital outcomes for young children.

1. Gaps to address in program design and practice

• Public works programs will benefit from greater attention to the needs of caregivers and young children, with accompanying evidence to inform program design and implementation. Quality childcare for workers engaged in traditional public works such as construction, irrigation or agricultural sub-projects can help address the lack of high-quality care alternatives for caregivers – often women – thereby increasing female labor participation, potentially improving child development outcomes, and increasing school participation among older siblings. There is also a greater scope for developing caregiver and child sensitive public work sub-project models, including less physically demanding work with flexible hours, as well as the introduction of childcare as a public works sub-project modality or training public work participants to deliver parenting programs. As these programs scale-up and expand into new contexts, it will be important to integrate program evaluation and learning to ensure that accompanying measures are implemented effectively to achieve anticipated results while building on existing structures and services.

• The use of cash transfer programs in urban areas is rapidly expanding, with a parallel need to adapt accompanying measures. Propelled by the economic impacts of the COVID-19 crisis, cash transfer programs are being increasingly deployed in urban areas. Although many of the COVID-19 response

21

measures are designed as temporary, counter-cyclical support for workers who have lost access to their livelihoods, the use of cash transfer programs in urban areas will likely continue to grow, especially as urbanization continues to grow and solutions for poor, urban populations become more pressing. New modalities for service delivery of accompanying measures will need to tackle issues of social distance requirement, security, rapid scale up, need for increased focalization on the most vulnerable children (see Box 1 below). Accompanying measures which have been developed in largely rural areas will need to be adapted and evaluated to meet the needs of rapidly growing urban populations.

• Beyond the need to specifically consider applications to public works programs or the urban context, other operational priorities looking forward include: (1) a greater focus on monitoring and supervision to enhance program quality, for both structural and process quality as well as support to front-line staff; (2) the use of behavioral insights, including nudges, behavior change communication and the role of groups and peer support as cost-effective design features to inform program design and enhance impacts; and (3) further adaptation and use of technology for elements of service provision as well as training of frontline workers, particularly during the period of COVID-19 response and recovery.

3 Griffith, R., O’Connell, M. and Smith, K. (2016), ‘Shopping around: how households adjusted food spending over the Great Recession’, Economica, 83(330), 247–80. Adda, J., Banks, J. and von Gaudecker, H.-M. (2009), ‘The impact of income shocks on health: evidence from cohort data’, Journal of the European Economic Association, 7(6), 1361–99. World Health Organization (2011), ‘Impact of economic crises on mental health’ http://www.euro.who.int/__data/assets/pdf_file/0008/134999/e94837.pdf 4 Almond, D, J Currie and V Duque (2018). “Childhood circumstances and adult outcomes: Act II”, Journal of Economic Literature, 56(4), 1360-1446 Currie, Janet, and Douglas Almond. “Chapter 15 - Human Capital Development before Age Five” In Handbook of Labor Economics, edited by David Card and Orley Ashenfelter, 4:1315–1486. Elsevier, 2011. https://doi.org/10.1016/S0169-7218(11)02413-0.

Box 1: Mobilizing accompanying measures to support parents and children during COVID-19

Disruptions in economic activity, increased uncertainty and reduced access to essential services due to the COVID-19 crisis are causing stress and a greater economic burden for parents and children. Parental anxiety, depression, substance use, loneliness, and domestic violence are likely to increase during COVID-19.3 Young children are likely to experience high levels of stress, anxiety and a heightened risk of violence and abuse. Chronic exposure to elevated levels of stress hormones can affect brain and behavioral development with long-lasting impacts on health, risky behaviors, and violence for children. The economic downturn will further affect human capital accumulation. Shocks during the prenatal period and in the first years of life have persistent and profound consequences for adult cognitive, health and labor market outcomes.4

The negative impacts of the crisis will not be distributed equally. Poor and vulnerable parents are less able to provide safe, stable and stimulating home environments, food security, nurturing care, and playful parenting. Disruptions in public services disproportionately affect children from disadvantaged families, who are more likely to rely on social programs, such as nutrition and early childhood programs. The impact of the crisis is expected to be most damaging for children in the poorest countries, the poorest neighborhoods, and for those in already disadvantaged or vulnerable situations.

However, there is a risk that early years interventions will not be prioritized as part of the COVID-19 response. Responding to the crisis in the short term requires protecting households from income losses but also ensuring access to basic early years services such as prenatal care, vaccinations, growth monitoring, and parenting programs. Cash transfer programs will need to consider adapting existing accompanying measures to continue supporting parents and children. Some examples of adaptations have included:

http://www.euro.who.int/__data/assets/pdf_file/0008/134999/e94837.pdf

22

2. Gaps to address in research and evidence

• Evidence is needed on the cost-effectiveness of alternative accompanying measures, as well as impacts and sustainability when implemented at scale. More evidence is needed to understand the contribution of different accompanying measures on a wide range of child outcomes. For instance, parenting programs seem to be more effective at improving cognitive outcomes than nutritional outcomes, while the inverse is true for nutrition interventions (Arriagada et al. 2018). Evidence from early childhood interventions sometimes reflects small scale programs implemented in better controlled environments. Cash transfer programs provide a unique opportunity to understand the value add of early childhood interventions when implemented at scale.

• Operational research is needed on core elements of early years interventions. More operational research is needed to build evidence that can help inform program choices surrounding content, materials, intensity, incentives for workers and delivery modalities in order to contribute to better and more sustained benefits for young children and families. Some of the questions that need to be answered: Which curriculum? What is the optimal dosage? How to effectively provide incentives to frontline workers? Which delivery modality or combination of delivery modalities should be used? For instance, the use of multiple delivery modalities is an area for further exploration as complementarities exist that can enhance program impact over the use of a single modality. SMS or voice messages can also be used to reinforce messages delivered through home visits.

• Understanding fidelity of implementation and program quality is critical. The assessment of program impacts needs to be complemented with assessments of implementation reflecting deviations from program design. In addition, program quality is a key driver of final impacts on children’s outcomes. The effectiveness of frontline workers has important implications for the quality of interactions with parents and between parents and children, with ultimate results for children’s development. Attention to the quality of childcare services is particularly important as low quality childcare might be worse than no childcare at all. The quality of child-caregiver interactions is a key determinant of impacts on children.

• Adapting counseling services using tele-visits. In Peru, Cuna Mas is reviewing its operational guidelines to provide counseling services remotely using phone services and technology. Cuna Mas also developed a remote community surveillance strategy using its network of social promoters to monitor the situation of beneficiary children and families. The surveillance relies on several communication means including SMS, WhatsApp or phone calls, and seeks to strengthen preventive measures, healthcare, hygiene, nutrition and learning practices, including practices to prevent the spread of COVID-19.

• Promoting child stimulation, health and nutrition through radio, SMS and videos. During periods of lockdown, programs can share information with parents on activities or toys they can make at home (e.g. building a ball with socks) or coping strategies. In Guatemala, the activities from the Reach Up parenting curricula have been adapted to phone messages and radio skits to support parents and children while home visits are suspended. In Rwanda, radio and TV are used to provide key messages to the general population to remind them that health facilities continue to provide key health services while promoting measures to prevent COVID-19; and food distributions are available in the community.

• Using food or cash distribution programs to provide early stimulation kits and information to parents. In Mexico and Ecuador, printouts from the new Reach Up Parental Manual for child stimulation developed for the COVID-19 emergency by the Reach Up team are being distributed to parents.

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• The influence of context on measurement needs more research. The proper selection, adaptation and validation of child development instruments is important to being able to adequately measure the effects of the intervention (Fernald et al. 2017b). Efforts to measure program impacts in the early years should be combined with more understanding on how the instruments work under different settings and administration modalities. The COVID-19 pandemic is not only challenging practitioners and policy makers on how to adapt program interventions but is also challenging researchers on how to measure the impact of those programs including through phone and internet-based data collection.

Conclusions

Cash transfer programs have proven to be a successful tool to promote child wellbeing during the early years. There is evidence of their effectiveness to reduce poverty, increase food consumption and the use of health services for pregnant women and young children, and, in some cases, improve family well-being and children’s nutrition, health and development. By attaching accompanying measures to the payments, cash transfer programs can be utilized to enhance investments in children’s human capital. This practice has been widely adopted, especially among family-focused cash transfer programs and increasingly among public works programs. The use of accompanying measures to enhance the early years impacts of cash is being propelled by the very rapid expansion in the use of cash transfer programs, most recently as part of the response to COVID-19 where cash transfers are being deployed as an instrument of choice in combatting the economic impacts of the crisis.

However, there is limited evidence on the impact of combining cash transfers with accompanying measures, particularly using experimental designs to assess the value added and cost-effectiveness of the accompanying measures. The research and evidence have not caught up with the practice, even as the practice expands. Currently, the shortfall of evaluations of programs that combine cash transfers and early years focused accompanying measures makes it difficult to draw comparisons across programs and to reach any definitive conclusions. This is particularly true for evaluations of nutrition-focused accompanying measures, which among the case studies reviewed only identified the unique impacts of the accompanying measures in two cases (Yemen and Nigeria). There is sparse evidence overall on the impact of taking accompanying measures to scale, the cost-effectiveness of using alternative delivery modalities, and the sustainability of results.

Looking forward, policy and program design related to accompanying measures would benefit from structured operationally focused research across programs. Examining a common set of practical questions on how to best design accompanying measures and combine them with cash transfer programs would significantly enhance both the evidence base and the applicability to ongoing practice. Building evidence to better inform program choices, notably on elements of content and service delivery including utilization of technology, have the potential contribute to more sustained benefits for young children and families.

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Annex: Detailed Case Studies

Each of the detailed case studies include a brief overview of the cash transfer program and selected child development accompanying measure including key details of service delivery, institutional coordination, and program outcomes based on impact evaluations. Summary tables at the end of each case allow for comparison of the similarities and differences between the selected accompanying measures, and a brief list of key references and resources is included with each case. Several of the safety net programs identified here have more than one accompanying measure associated with the program, however only one has been selected for further examination within each case study. A brief list of references and resources are included at the end of each case study to provide readers with additional information if needed.

Nutrition-Focused Accompanying Measures of Cash Transfer Programs ..................................................... 28 Bangladesh: Scaling up a successful pilot to improve nutrition outcomes for the poor .................................................. 28 Indonesia: Nutrition-sensitive family sessions improve nutrition outcomes and reduce stunting .................................. 30 Mali: Integrated intervention of cash transfers, accompanying measures, and nutrition packages ............................... 32 Nigeria: Enhanced knowledge and behavior change reduce stunting and child illness in northern Nigeria ................... 34 Senegal: Linking cash transfers and a nutrition communications campaign to a national platform ................................ 36 Yemen: Nutrition-sensitive cash transfers address child malnutrition in fragile and conflict setting .............................. 38

Parenting-Focused Accompanying Measures of Cash Transfer Programs .................................................... 40 Brazil: Largest home visiting program promotes parenting practices and nurturing care ............................................... 40 Burkina Faso: Social and behavior change communication enhances parenting practices ............................................. 43 Colombia: Mother leaders deliver psychosocial and nutritional accompanying measures ............................................. 45 Madagascar: Behavioral nudges increase parental investment in the early years .......................................................... 47 Mexico: Integrated programs enhance early stimulation, parenting, timely detection and care .................................... 49 Program 1: Promotion and Care of Child Development (PRADI) ...................................................................................... 49 Program 2: Educacion Inicial (EI) ....................................................................................................................................... 50 Niger: Incorporating psycho-social stimulation in response to household needs ............................................................ 52 Peru: A home visiting service in poor, rural and marginalized communities ................................................................... 54

Accompanying Measures of Public Works Programs .................................................................................. 56 Burkina Faso: A pioneer in mobile creche implementation at public works sites ............................................................ 56 Cameroon: A mobile creche pilot with childcare provision and parental education ....................................................... 58 Djibouti: Integrated public works and nutrition interventions focus on participation of women ................................... 60 Madagascar: Applying ECD best practices from a cash transfer program to a public works program ............................ 62 Rwanda: Introducing home-based early childhood development as a separate public works component .................... 64

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Nutrition-Focused Accompanying Measures of Cash Transfer Programs

Bangladesh: Scaling up a successful pilot to improve nutrition outcomes for the poor

Despite significant economic growth, poverty reduction and human development, undernutrition among mothers and young children remains a key challenge in Bangladesh. Children’s nutritional status has improved; however, 35 percent of the population remains food insecure. The prevalence of stunting is among the highest in the world at 36 percent and disproportionately affects young children and children living in poverty. The combination of stunting, low birthweight, poor maternal nutrition and early marriage has contributed to the transmission of malnutrition between mothers and their children. Jawtno, meaning “nurture” in Bangla, is a conditional cash transfer program launched in February 2017 to reach pregnant women and mothers of children under 5 in the bottom 40 percent of the income distribution. The program builds on the experience of a pilot CCT, Shombhob, which showed rapid results in reducing undernutrition and wasting. The program aims to enroll 600,000 poor mothers in seven districts across the country to receive cash transfers based on a set of health and nutrition conditions including antenatal care, growth monitoring and promotion, and counseling services.

Nutrition Accompanying Measure The accompanying measure for better nutrition includes nutrition services and counseling sessions focused on child nutrition and cognitive development. The nutrition services for pregnant women and mothers through Jawtno include monthly antenatal care and growth monitoring and promotion sessions for children under five. Group-based counseling sessions are delivered monthly on key topics related to child nutrition and cognitive development to help mothers understand how to best care for and feed their children, and the linkages between the physical and cognitive development of young children. Topics include pregnancy care, age-specific nutrition, hygiene and sanitation, parenting skills, and child stimulation. The counseling sessions are linked to health clinic visits and introduce a single topic related to nutrition and child cognitive development each month. During these sessions, child cognitive development topics are presented in the form of scenarios and play to promote interaction, and discussions are tailored to different groups of mothers or families based on the culture of the local communities, which include tribal populations. Feedback is provided to parents and caregivers on early childhood cognitive development to improve knowledge and awareness on early childhood development.

Service Delivery Local government bodies manage overall implementation of the cash transfer program, whereas antenatal and growth monitoring and promotion services are provided through Community Clinics (CC). In Bangladesh, local governments provide a variety of public services and coordinate safety net implementation, which is complemented by the role of the CC to ensure the provision of primary healthcare services for poor and vulnerable populations. NGO staff deliver child nutrition and cognitive development sessions and work alongside the CC, to ensure adequate service delivery and to help manage demand. The sessions occur once a month for an average of one hour and are based on interactive, component, or conversational learning. The curriculum utilizes global best practice including the Jamaica Home Visit Program and was adapted based on lessons learned from the Shombhob pilot. The cognitive development component is based on Reach Up and also incorporates children’s books and toys developed by the Child Development Unit of the International Centre for Diarrheal Disease Research in Bangladesh. Regular spot checks are conducted every six months to monitor the quality of services and receive beneficiary feedback and assessment regarding the accompanying measure.

29

Institutional Coordination Jawtno brings to the national scale a package of early years services provided through a network of community clinics, post offices and mothers’ groups. Delivery of the accompanying measure is supervised by the Ministry of Local Government through the Local Government Division (LGD) while health services are managed by the Directorate General of Health Services (DGHS). The LGD hires local NGOs to work alongside community clinics and supports close collaboration among the service providers to ensure the supply of health and nutrition services meets the demand of the beneficiary population. The National Nutrition Service (NNS) in Bangladesh leads national efforts to combat malnutrition through community-based efforts to promote positive nutrition practices. Community clinics serve as the main local contact points for the nutrition services.

Impact Evaluation There is an ongoing impact evaluation of the nutrition accompanying measure. Baseline household survey data was collected in December 2018 and a child cognitive development survey was completed in August 2019. An impact evaluation of the Shombhob pilot showed that the CCT had significant impacts on poverty reduction and nutrition. Household consumption among beneficiary households increased by 70 percent of the average transfer size, including a significant increase in food expenses on proteins particularly for households that received the nutrition awareness sessions. Wasting was reduced by 12.5 percentage points among children aged 10-22 months, which represented a reduction of about 40 percent for this age group (Ferre and Sharif, 2014). Knowledge on infant feeding practices increased, including for exclusive breastfeeding, and the evidence overall supported the importance of promoting nutrition interventions during the first 1,000 days.

Summary Table – Nutrition AM (Bangladesh)

References and key resources

Ferre, Celine; Sharif, Iffath. 2014. Can conditional cash transfers improve education and nutrition outcomes for poor children in Bangladesh? evidence from a pilot project. Policy Research working paper; no. 7077. Washington, DC: World Bank Group. Nomura, Shinsaku; Matsuda, Norihiko. 2017. Building the Human Capital of Tomorrow - An Impact Evaluation of the Early Childhood Stimulation Program (English). Washington, DC: World Bank.

World Bank. 2017. From Pilot to Scale: Engaging local governments and established local service providers in the Jawtno conditional cash transfer program. http://documents.worldbank.org/curated/en/528691542268278913/pdf/WBG-2017-bangladesh-jawtno-case-study.pdf

Target Population

Delivery Modality and Frequency Topics Curriculum SBCC Strategies Frontline

Workers Group-based

Individual visits Other

Pregnant women,

mothers of children under

5

Monthly Health

clinic visits; Monthly

--

Child nutrition, cognitive

development

International Center for

Diarrheal Disease Research; Reach

Up



NGO Staff: Literacy required

Paid monthly

http://documents.worldbank.org/curated/en/528691542268278913/pdf/WBG-2017-bangladesh-jawtno-case-study.pdf

http://documents.worldbank.org/curated/en/528691542268278913/pdf/WBG-2017-bangladesh-jawtno-case-study.pdf

30

Indonesia: Nutrition-sensitive family sessions improve nutrition outcomes and reduce stunting

Stunting is a widespread and persistent problem in Indonesia that affects more than 6.5 million, or 27.7 percent, of all children under five. Prevalence of exclusive breastfeeding, age-appropriate complementary feeding, dietary diversity, and improved sanitation lag behind that of neighboring countries. In general, health and education indicators have not improved in line with the country’s macroeconomic growth. Launched in 2007, Indonesia’s CCT Program Keluarga Harapan (PKH) incentivizes utilization of basic health and education services. The program targets the bottom 15 percent of families with pregnant or lactating women, and households with children under 18 that have fewer than nine years of education. Conditions include participation in pre-natal care, post-natal care, immunizations, growth monitoring check-ups, and participation in regular health checkups. As of December 2018, PKH benefited ten million poor families, or forty million individuals in Indonesia.

Nutrition Accompanying Measure Family Development Session (FDS) modules were designed to accompany the PKH cash transfer and help beneficiary mothers develop key life skills and adopt positive behaviors for children´s development. One module focuses on raising awareness and providing advice to beneficiary mothers on improved behaviors to enhance health and nutrition outcomes.5 The FDS health and nutrition content has been recently enhanced to focus on improved behaviors and practices during the first 1,000 days and covers three key areas: health and nutrition services for pregnant women, nutrition for lactating mothers and toddlers, and child illnesses and environmental health. The target group includes women who are pregnant, lactating women and/or mothers with children aged 0-6. A separate education and parenting module focuses on the early years and covers parenting practices, understanding children’s behavior, playing and learning, and success in school. The FDS modules were initially designed to help beneficiary families graduate from the program after six years and provide additional structure and purpose to the monthly meetings. Starting in 2017, MoSA has scaled up the FDS nationwide.

Service Delivery The FDS modules are implemented by certified PKH facilitators through structured learning sessions delivered at monthly group meetings for beneficiary mothers. FDS sessions are introduced into existing monthly group meetings by the group’s facilitator to share relevant information, and group members are encouraged to discuss related problems that they face. For the health and nutrition module, FDS facilitators educate beneficiary women about health and nutrition, support mothers and children to access essential health services, and inform social workers or midwifes about individuals who require additional consultation or a special visit. The messages are reinforced through games, interactive and group activities, and individual support based on specialized needs. FDS facilitators are trained by the Ministry of Social Affairs (MoSA) and a technical manual provides a step-by-step guide for leading the health and nutrition sessions.6 In addition to the sessions, pregnant and or lactating mothers and preschoolers are required to visit Puskesmas (health clinics) and Posyandu (community health workers) for health check-ups, growth monitoring and nutrition supplementation as a condition of the CCT. PKH facilitators are hired through a competitive process and paid directly by MoSA. Facilitators must have a diploma and participate in a 4-6-day basic training led by the MoSA on PKH operations as well as a separate FDS training program.

5 Five FDS modules cover health and nutrition, child protection, education and parenting, family finance, and social welfare. 6 The key messages delivered to beneficiary women and their families by FDS facilitators are included in the FDS Health and Nutrition Module Technical Guide: http://documents.worldbank.org/curated/en/482881538561607599/pdf/Indonesia-FDS-HN-Module-English.pdf

http://documents.worldbank.org/curated/en/482881538561607599/pdf/Indonesia-FDS-HN-Module-English.pdf

http://documents.worldbank.org/curated/en/482881538561607599/pdf/Indonesia-FDS-HN-Module-English.pdf

31

Institutional Coordination The MoSA coordinates delivery of PKH including the FDS health and nutrition module. While the PKH and FDS modules are national-level programs, implementation relies heavily on the sub-national network of MoSA staff and Social Affairs Offices as well as support and collaboration from local government stakeholders including health sector officials for the FDS modules. Provincial coordinators help to ensure that local health and education services are available to beneficiaries and identify areas where they are not. The MoSA encourages the local government to cost share and contribute five percent of the total PKH allocation, which is primarily used for communications and outreach activities, and staff and operational costs. The World Bank and UNICEF provided technical support for the development of the initial FDS modules whereas the recent revision of the health and nutrition module was carried by the World Bank and WFP. There are structures for inter-sectoral coordination at subnational and national levels, which involve participation from various ministries including Health, Education and Culture, Planning and Development, and Women’s Empowerment and Child Protection. However, greater coordination is required regarding beneficiary access and monitoring participation in FDS health and nutrition modules.

Impact Evaluation While the impact evaluation of PKH has not separately studied the added value of the accompanying measures from the family sessions (FDS), it found that PKH improved nutrition and healthy behaviors. Evidence shows PKH increased consumption of protein-rich food, had positive impacts on healthy behaviors with respect to maternal and neo-natal practices and reduced stunting (World Bank 2011, Cahyadi et al. 2018). However, a qualitative study found that the behaviors promoted in the modules need to be complemented by sufficient supply of services, especially where community-level communication campaigns are carried out. Interviews with beneficiaries and communities indicate that in the areas where the program was successful in changing behaviors, it was primarily due to the quality of facilitators and their encouragement to local authorities and community groups of the benefits of PKH behaviors.

Summary Table – Nutrition AM (Indonesia)


Cahyadi, N. Hanna, R. Olken, B. Prima, R. Satriawan, E. Syamsulhakim. (2018).” The Cumulative Impacts of Cumulative Impacts of Conditional Cash Transfer Programs: Experimental Evidence from Indonesia”. NBER Working Paper No. 24670.

World Bank. 2018. Indonesia - Cash, Counseling, and Community Mobilization: Providing Nutrition-Sensitive Training and Mobilizing Communities in the PKH Conditional Cash Transfer Program (English). Washington, D.C.: World Bank Group.

World Bank. 2018. Health and Nutrition Module - Family Development Session (FDS) Family Hope Program (Program Keluarga Harapan, PKH): Technical Guide for the FDS Implementation (English). Washington, D.C.: World Bank Group.

World Bank. 2017. Social assistance reform program: technical assessment (English). Washington, D.C.: World Bank Group.

World Bank. 2011. “Program Keluarga Harapan: Main findings from the Impact Evaluation of Indonesia’s Pilot Household Conditional Cash Transfer Program.” Jakarta: World Bank.

World Bank. 2020. Investing in People: Social Protection for Indonesia's 2045 Vision. Washington, D.C.: World Bank Group. https://hubs.worldbank.org/docs/imagebank/Pages/docProfile.aspx?nodeid=31954125

Target Population


Strategies Frontline Workers Group-

based Individual

visits Other Pregnant women,


Monthly

Health clinic visits and referrals; Monthly

-- Maternal and child health and nutrition

Government of Indonesia;

support from WB and UNICEF



Program Facilitators:

Diploma required Paid monthly

https://hubs.worldbank.org/docs/imagebank/Pages/docProfile.aspx?nodeid=31954125

32

Mali: Integrated intervention of cash transfers, accompanying measures, and nutrition packages

Mali faces high levels of extreme poverty and food insecurity as well as low levels of human development, with slow progress in health and education. Child mortality and child malnutrition are high, particularly in the southern regions, and less than half of children complete primary school. Nationally, stunting rates have decreased over time to 27 percent (compared to 38 percent in the south), and anemia rates are extremely high throughout the country at 82 percent. Chronic poverty, climate vulnerability, conflict and insecurity, low levels of human capital, and high rates of fertility and population growth indicate an urgent need for social safety net interventions with a focus on building children’s human capital. In 2014, the Government of Mali began implementing the Filets Sociaux (Jigisémèjiri) program, which combines cash transfers, accompanying measures, and preventive nutrition packages (PNP) to reduce poverty and enhance human capital. The integrated program targets children under five years and pregnant and lactating women across six regions and in Bamako district. As of July 2019, the cash transfer component reached approximately 62,000 poor households, or 400,000 individuals. In the short-term, the cash transfer intended to alleviate current poverty and vulnerability by smoothing and increasing household consumption. In the medium-term, the integrated approach, with accompanying measures and nutrition packages, aimed to improve children’s human capital and reduce the intergenerational transmission of poverty.

Nutrition Accompanying Measures The accompanying measures provide complementary information sessions that incentivize household investment in children’s human capital and maximize the benefits of the cash transfers. The information sessions encourage households to use the cash transfers to fulfill essential needs, and also promote the adoption of good practices for infant and young child feeding, maternal nutrition, health, education, family planning, hygiene and sanitation, savings, and investment. Although cash transfers were targeted, the accompanying measures were not targeted and were made available to all households in the program communes, or approximately 283,000 households. Beneficiary households were encouraged, but not required, to attend. The preventive nutrition packages were implemented in 20 communes, based on nutritional needs and the presence of other nutrition programs. The packages consisted of fortified flour and were distributed to pregnant and lactating women and children under 5 in order to prevent maternal and child malnutrition.

Service Delivery For the accompanying measures, NGOs conduct two training sessions per month in each intervention village. Sessions are organized into six groups of themes, each of which lasts for a period of 6 months (see table). The government designed the curriculum for the sessions and conducts regional trainings for the NGO on each theme. Health center doctors participate in the regional trainings to provide context-specific health information, and NGOs adapt the messages to local context and language with the help of village- and circle-level health staff. NGOs also develop a dissemination strategy, using images or radio, and trains fieldworkers. Fieldworkers have access to curriculum materials developed by the government. Information is also communicated to beneficiaries at cash transfer payment sites, to reach additional beneficiaries who may not attend information sessions. Local NGOs were contracted to organize the PNP distribution in selected communes

Series Themes related to ECD 1 • Exclusive Breastfeeding 2 • Complementary Feeding (includes PNP cooking

demonstration sessions) 3 • Prenatal and postnatal consultations

• Nutrition practices, especially for women, pregnant women, and sick and malnourished children

• Children’s rights – vaccination calendar and birth registration

4 • Respiratory infections of children • Water, Hygiene and Sanitation (WASH)

5 • Universal health and sickness coverage • Importance of education for children and teenagers,

especially girls

33

and to organize cooking demonstrations on how to prepare food using fortified flours. Caregivers were also informed that the flour does not replace breastfeeding, and that women should practice optimal breastfeeding.

Institutional Coordination The program is managed by the Unite Technique de Gestion Filets Sociaux (UTGFS) under the Ministry of Economy, Finance and Budget (MEFB). The National Steering Committee (NSC), established for the project through a Prime Minister decree, is charged with approving and overseeing the activities of the UTGFS. The NCS provides policy orientation and supervises project implementation, whereas the UTGFS is responsible for day-to-day project management, implementation, and reporting. NSC members consist of representatives from relevant sectoral Ministries. At the regional level, project implementation is conducted in collaboration with the Ministry of Solidarity, Humanitarian Action, and Reconstruction of the North (MSAHRN). At the district level, UTGFS agents coordinate with social services within the MSAHRN structure, and are responsible for identifying beneficiaries, implementing daily project activities, and coordinating and communicating with communities and beneficiaries. A committee with representatives from civil society, NGOs, and civil servants of technical services help identify targeted households in each village.

Impact Evaluation An impact evaluation conducted by the Government of Mali, International Food Policy Research Institute (IFPRI) and Institut de Recherche pour le Développement (IRD) assessed how the Jigisémèjiri program affects household welfare and child nutrition and health (Hidrobo et al., 2019). The evaluation compares outcomes between communes that started receiving the program in 2014 (early treatment) and those that started receiving the program in 2016 (late treatment). The evaluation found that consumption and dietary diversity increased over time, and rates of poverty and food insecurity decreased. However, the evaluation was not able to differentiate between the separate impacts of the cash transfer and accompanying measure components due to limitations in the program design. The PNP did significantly reduce chronic child undernutrition as measured through length-for-age and rates of anemia, but it had no impact on IYCF practices, dietary diversity, or child morbidity. Given the inconclusive results of the accompanying measures and cash transfers for early childhood development, the next phase of the program will include home visits to poor households with children to enhance the impact of the cash transfers on child and parental behavior (World Bank, 2018).

Summary Table – Nutrition AM (Mali)

References and key resources World Bank. 2018. Combined Project Information Documents: Safety Nets Project (Jigisemejiri).

Hidrobo, Melissa; Roy, Shalini; Huybregts, Lieven; Njee-Bugha, Leila; Karachiwalla, Naureen; Kameli, Yves. 2019. Filets Sociaux (Jigisemejiri) program endline report (draft). Programme de Filets Sociaux au Mali, International Food Policy Research Institute, and Institut de Recherche pour le Développement.

Target Population



based Home visits Other

Pregnant women, mothers of children under

5

Twice per month

(open to all)

--

Preventive Nutrition

Packages (PNP)

Maternal and child health and nutrition,

family planning, hygiene

Government of Mali; NGO staff

and doctors adapt to local context

Peer-to-Peer, Information on Payday, Media

NGO Staff: Paid

monthly

34

Nigeria: Enhanced knowledge and behavior change reduce stunting and child illness in northern Nigeria

Nigeria is the most populous country in Africa and has one of the largest youth populations in the world yet ranks among the lowest in the world on the World Bank’s Human Capital Index. The north in particular has experienced high levels of poverty, hunger, malnutrition, and infant and maternal mortality. The Child Development Grant Program (CDGP) is a pilot cash transfer program implemented in northern Nigeria that provides unconditional monthly cash transfers to pregnant women until their child reaches age two. The primary objective of the CDGP is to reduce poverty, hunger and malnutrition by promoting improvements in household food security and maternal and child health practices to promote child survival and development. The program is implemented in one of the most vulnerable regions of Nigeria where infant mortality rates reach 90 out of 1,000 children, nearly 70 percent of children are stunted, and 85 percent of households live in extreme poverty.

Nutrition Accompanying Measure for nutrition The accompanying measures of the unconditional cash transfer program in the first 1000 days provide information to mothers and fathers regarding improved practices for pregnancy, childcare, and nutrition, particularly infant feeding. The information messaging is tailored to the local context based on existing knowledge gaps among the rural poor and particularly pregnant women. The behavior change campaign aims to influence maternal and childcare practices and is supplemented by parenting and counseling sessions targeted towards specific groups and individuals. Eight key messages were disseminated according to three periods of pregnancy: (1) prenatal – attend antenatal care and eat one additional meal during pregnancy; (2) perinatal – breastfeed immediately and breastfeed exclusively; (3) postnatal – practice complementary feeding, good hygiene and sanitation, use health facilities, and consume nutritious food. Program-specific information, education and communication (IEC) materials have also been developed.

Service Delivery Information messages were delivered through both low- and high-intensity channels which are organized and implemented by locally hired community volunteers. Low-intensity channels included posters, radio, religious teachings, health talks, food demonstrations, and pre-recorded SMS or voice messages. These aim to reach eligible beneficiaries as well as members of the broader community, including young women who are not yet pregnant, and men and older women who are influential village members. High-intensity channels included small group parenting sessions focused on nutrition and health practices, and one-on-one counseling conducted during home visits. Locally hired community volunteers (CVs) were trained by the CDGP to deliver information messages and implement the program on a daily basis at the village level. CVs consist of both one lead CV per village who has basic skills and is further trained for a specialized counseling role, as well as two nutrition promoter CVs per village who share information on recommended practices and refer women to CDGP staff as needed. While both work part-time for approximately 25 hours per month, the lead CV is paid whereas the nutrition promotion CVs receive a stiped and certified training.

Institutional Coordination The CDGP was a six-year pilot program funded by the Department for International Development (DFID) in northern Nigeria. Two international NGOs, Save the Children (SCI) and Action Against Hunger (AAH), implemented the program. The intervention was designed to inform an evaluation on the impact of CDGP on food security and nutrition and reached nearly 70,000 households in Zamfara and Jigawa states. The community volunteers were responsible for much of the program implementation and coordination with government counterparts. Certain government staff and Community Health Extension Workers (CHEWs) were seconded to support program

35

activities in the focus areas, notably for supervision of community volunteers, however in large part the CDGP relied on financial resources and NGO capacity provided by DFID and international implementing partners, SCI and AAH7. The SBCC messages provided to beneficiaries were in line with the Community Infant and Young Child Feeding (C-IYCF) Counselling Package promoted by the Government of Nigeria regarding healthy behaviors during pregnancy, breastfeeding, complementary feeding practices, and hygiene.

Impact Evaluation The behavioral change component increased child height by 0.62 cm and reduced stunting by 8% as well as improved dietary diversity and reduced child injury and illness (Carneiro, 2019). Information-related channels such as improved knowledge, practices and health behaviors of mothers towards newborns play an important role in contributing to these impacts. Parental practices towards children during the first 1,000 days improved significantly: mothers are 86 percent more likely to access antenatal care; 37 percent more likely to breastfeed immediately upon birth; and three times as likely to exclusively breastfeed for the first six months. Young children are also more likely to receive deworming medication and basic vaccinations. Positive impacts are also seen through resource-related channels, including food security and dietary diversity, extreme poverty reduction, and increased labor supply, business investments, and livestock ownership among women. These latter effects reflect the potential for enhanced resource allocation among mothers to translate into increased investments in children’s human capital.

Summary Table – Nutrition AM (Nigeria)

References and key resources Carneiro, Pedro; Kraftman, Lucy; Mason, Giacomo; Moore, Lucie; Rasul, Imran; and Molly Scott. November 2019. The Impacts of a Multifaceted Pre-natal Intervention on Human Capital Accumulation in Early Life. http://www.homepages.ucl.ac.uk/~uctpimr/research/CDGP.pdf

Nnabugwu, Adetoun; Visram, Aly; Kardan, Andrew; and Molly Scott. Evaluation of the Child Development Grant Programme. https://www.opml.co.uk/projects/evaluation-child-development-grant-programme-cdgp

7 It is important to note that CDGP was designed as a pilot program to demonstrate the potential impact of a nutrition-sensitive cash transfer program in the context of northern Nigeria and was not intended to be continued by implementing partners or government stakeholders beyond the timeline of the evaluation. Therefore, institutional coordination and capacity building were not a key focus of program implementation. See Process Evaluation for additional information.

Target Population



based Individual

visits Other

Pregnant women,


Monthly (‘high

intensity’)

Home visits (‘high

intensity’)

Radio, posters,

SMS (‘low intensity’)

Pregnancy, childcare,

nutrition, and infant feeding

practices

Save the Children and

Action Against Hunger; aligned with Government IYCF messaging

Discussions, Peer-to-Peer,

Media, Demonstrations

Community Volunteers:

Literacy required

Paid monthly

http://www.homepages.ucl.ac.uk/%7Euctpimr/research/CDGP.pdf

https://www.opml.co.uk/projects/evaluation-child-development-grant-programme-cdgp

36

Senegal: Linking cash transfers and a nutrition communications campaign to a national platform

As of 2000, malnutrition was a significant concern in Senegal as nearly one in every three children under five years were stunted, one in ten were wasted, and one in five were underweight. Malnutrition contributed to high levels of child and maternal mortality and morbidity, low human capital development, and unmet potential in household productivity and economic development. In 2001, the Government of Senegal launched the Nutrition Enhancement Program (NEP) to improve nutrition through a community-based, multisectoral approach that leverages broad participation to deliver training, micronutrients and assets. The community-centered nutrition approach supports a network of caregivers and community agents to support growth promotion and management of acute malnutrition and childhood illnesses in addition to food security, health and nutrition initiatives. Following the global financial crisis of 2009, a pilot child-focused social cash transfer was integrated into the NEP to mitigate the risks of food and nutrition insecurity to human capital formation among mothers of children under five and pregnant and lactating women. The pilot cash transfer program operated in 10 critical districts with high rates of poverty, malnutrition, and household food insecurity.

Nutrition Accompanying Measure The cash transfer component of the NEP provides an unconditional cash transfer to eligible mothers to support the purchase of nutritious foods and other services that promote the development of children.8 It builds on the longstanding implementation approach utilized by the NEP, including local services, networks, and existing stakeholders at the local, regional, and national levels. As a result, the Senegal case study is unique in that it discusses a cash transfer component that was added onto an existing community-based nutrition platform during a time of crisis – an adaptive safety net program.9 In addition to the existing NEP interventions already present in each community where the cash transfer was introduced, the cash was also accompanied by a robust communications campaign that delivered messages on maternal and child health and nutrition to promote the purchase of nutritious foods, improve health and nutrition behaviors, and enhance access to ECD and health services. The messaging also encourages mothers to register their children at birth. The multi-part campaign aimed to include all community members who serve as caretakers themselves or have the potential to influence others who care for children. It was emphasized that the cash transfers were intended to protect and promote the nutritional well-being of children under five.

Service Delivery The cash transfer and SBCC accompanying measures relied largely on existing NEP structures and processes for implementation. The cash transfer was delivered largely through the pre-existing healthcare network, which also incorporated an additional communication campaign on improving child nutrition. The communications campaign consisted of large community meetings that included interactive discussions, theater and songs; group-based parenting education sessions; orientation and decision meetings with local authorities; and one-on-one counseling services as needed. Group education sessions were delivered monthly on different themes that raise and promote discussion on common problems related to pregnancy and child growth. These themes and messages are identified and developed based on the characteristics and problems of each locality alongside UNICEF programming. The communication method is participative in which nutrition aides act as facilitators. The front-line staff consisted both of trained outreach workers as well as volunteer mother leaders selected from among their communities. Nutrition aides’ function on a primarily volunteer basis with some incentives such as

8 The cash transfer program is known locally as the Projet nutrition ciblée sur l’enfant et transferts sociaux or NETS. 9 In the paper that outlines the “cash plus” framework during the early years, Arriagada et al. (2018) refer to this as “piggybacking model” in which the CT program uses an existing platform to deliver cash and accompanying measures.

37

continuous training, performance-based bonuses, and community contributions in kind. Delivery of the sessions is supported by a community executing agency.

Institutional Coordination The child-focused social cash transfer and nutrition accompanying measure was implemented by the Cellule de Lutte contre la Malnutrition (CLM) as one component of the overall management and execution of the NEP. Housed in the Prime Minister’s Office, the CLM has primary responsibility to coordinate and supervise the multiple actors involved in the NEP, as well as to oversee the high-level policy and strategy of the program. The National Executive Bureau serves as technical secretariat and an inter-ministerial steering committee serves as the program coordination mechanism at the national level. Three Regional Executive Bureaus serve as regional coordination mechanisms. At the local level, local governments monitor and report on activities and incorporate nutrition activities and indicators into Local Development Plans. Delivery of the cash transfers, including targeting and beneficiary selection, and of the accompanying measures are contracted out through a competitive process to a Community Executing Agency (CEA), which is typically an NGO or community-based organization that covers at least one district. The CEAs support all community-based nutrition activities and support integration of nutrition and growth promotion activities into the public health system.

Impact Evaluation An impact evaluation has been conducted to determine the short-term program effects of the child-focused cash transfer program (Sall et al., 2012). The impact evaluation measured the effects of the overall intervention package including both the cash transfer and the nutrition accompanying measure, rather than the distinct impacts of each. At the household level, the program led to increased food expenditures, an increase in the number of meals consumed, and a decrease in negative coping strategies. It was also found to increase maternal participation in the group education sessions and maternal and reproductive health, in addition to improved outcomes for children: increased dietary diversity, improved eating habits, use of growth monitoring card, reduction in diarrheal disease, and improved vaccination coverage.

Summary Table – Nutrition AM (Senegal)

References and key resources Independent Evaluation Group (IEG). 2016. Senegal: A Decade of World Bank Support to Senegal’s Nutrition Program (English). Washington, D.C.: World Bank Group.

Sall, Mohamadou; Dramani, Latif Armel Guy; Prevel, Yves Martin; Kameli, Yves; Fall, Abdou Salam. 2012. Évaluation de l’impact du transfert en espèces dans le cadre du projet nutrition ciblée sur l’enfant et transferts sociaux (NETS). Dakar, Senegal: LARTES-IFAN, Cheikh Anta Diop de Dakar.

World Bank. 2013. Senegal - Rapid Response Child-focused Social Cash Transfer and Nutrition Security Project (English). Washington DC: World Bank. http://documents.worldbank.org/curated/en/145231468103764507/Senegal-Rapid-Response-Child-focused-Social-Cash-Transfer-and-Nutrition-Security-Project

Target Population



based Individual

visits Other

Pregnant women,


Monthly


and counseling

; as needed

Village assembly;

Local authority meetings

Maternal and child health and

nutrition, access to ECD

and health services

Government of Senegal (NEP

structures), support from

UNICEF

Discussions, Play, Feedback

to Parents, Peer-to-Peer, Grandmother

Groups

Nutrition Enhancement

Program (NEP) (nutrition aides,

outreach workers, mother leaders)

http://documents.worldbank.org/curated/en/145231468103764507/Senegal-Rapid-Response-Child-focused-Social-Cash-Transfer-and-Nutrition-Security-Project

http://documents.worldbank.org/curated/en/145231468103764507/Senegal-Rapid-Response-Child-focused-Social-Cash-Transfer-and-Nutrition-Security-Project

38

Yemen: Nutrition-sensitive cash transfers address child malnutrition in fragile and conflict setting

Recent evidence has highlighted the potential for cash combined with nutritional education to lead to improved maternal and child health and nutrition outcomes in fragile and conflict settings such as Yemen (Kurdi et al., 2019). In these contexts, cash plus programs can help to address not only short-term food insecurity, and at the same time mitigate the longer-term impacts of conflict and insecurity, including chronic malnutrition, on young children. Even prior to the current civil conflict and humanitarian crisis in Yemen, children faced high rates of malnutrition: 46.5 percent of children under five were stunted and 16.3 percent were wasted. In January 2015, a pilot conditional cash transfer program was launched in Al Hodeidah governorate to address the high prevalence of child malnutrition. Conditions included attendance at monthly nutritional training sessions and compliance with health center referrals for monitoring and treatment of malnutrition. In late 2016, the program was expanded through the World Bank funded Yemen Emergency Crisis Response Project (ECRP), also known as “Cash for Nutrition” program. As of mid-2019, the program reached 88,000 poor and vulnerable pregnant women and mothers of children under the age of five across Yemen. The program provides one year of monthly cash transfers and nutritional training sessions, although conditions were softened during the program expansion.

Nutrition Accompanying Measure The monthly education sessions cover a number of topics related to infant and young child nutrition, health and hygiene. Nutrition topics included exclusive breastfeeding (children up to 6 months of age), complementary feeding (children from 6 to 24 months of age), the importance of balanced meals, and use of iodized salt. Women also receive training on proper hygiene and sanitation, treatment of drinking water, and management of diarrhea. Additional quarterly sessions covered topics particularly relevant for pregnant and lactating women such as breastfeeding initiation, importance of colostrum and not pre-lacteal feeding, hygiene and sanitation, the treatment of drinking water; as well as consequences of consuming qat and smoking during pregnancy. In addition to quarterly and monthly sessions, pregnant women were referred to the nearest health center for antenatal care, and periodic screening sessions were conducted during home visits to detect and refer cases of malnutrition to health centers for treatment.

Service Delivery The program employs community health educators, who are local women with at least a high school education, to lead the monthly educational sessions and monitor children in participating households. The community health educators are recruited locally and receive basic training in health and nutrition education and malnutrition screening. While attendance was tracked at the health and nutrition education sessions, conditionality was softened under the ECRP. Instead of penalizing non-attendance with reduced transfers, women who did not attend were contacted by educational volunteers and encouraged to attend future sessions through a case management approach. Even with the softened conditionality, attendance at the nutritional education sessions was high: 96 percent of surveyed households in communities that received the intervention reported participating in at least one session. The average number of sessions attended was 8.2 out of 9. Evidence also suggests that the benefits of the training sessions spilled over to non-participating households, as 26 percent of control households reported learning something new from the community health educator notably surrounding proper water treatment, knowledge of health center location, importance of iron-rich foods to prevent anemia, and knowledge of exclusive breastfeeding.

The prevalence of conflict has affected service delivery in many areas. In areas of active conflict with risk of air strikes, home visits are used instead of group nutritional training sessions, and cash transfers are distributed less frequently. The program also established a telephone hotline to respond to beneficiary questions. Women who

39

were forced to leave their homes are allowed to participate in training sessions and receive cash transfers in other districts where the program is active.

Institutional Coordination The Cash for Nutrition program is implemented by the Yemen Social Fund for Development (SFD) in coordination with the Ministry of Public Health and Population. Funded by the World Bank, the program is also supported by the United Nations Development Program (UNDP). The SFD is a quasi-governmental organization with objectives to improve basic services, enhance economic opportunities, and reduce vulnerability of poor households through a community-led development approach. While the program was originally designed to address high levels of child stunting in poverty in a focused geographic area, it was rapidly expanded and incorporated into the Yemen ECRP after the conflict broke out. These actions reflect the importance of heightened flexibility in program implementation, as well as improved coordination between humanitarian and development actors in contexts such as Yemen to ensure program reach and enhance impact.

Impact Evaluation An impact evaluation found that the Cash for Nutrition intervention effectively mitigated economic disruption, food insecurity, and poor health and nutrition outcomes for women and children caused by the civil conflict in Yemen (Kurdi et al., 2019). Between the 2015 and 2017, overall food security and nutrition in the country worsened according to several measures particularly for women and children. Despite the challenging context, the Cash for Nutrition program contributed to significant positive impacts on a range of intermediate and final outcomes including maternal knowledge, spending on food, prevalence of malnutrition, and anthropometric indicators. The share of children diagnosed with moderate or severe malnutrition decreased, and both height-for-age and weight-for-height of children in the poorest third of households improved. Dietary diversity of children and women rose significantly alongside increased consumption of fruits, vegetables, and animal products. The nutritional training improved knowledge and practices related to child nutrition such as early and exclusive breastfeeding and drinking treated water. Women’s empowerment also improved, as women beneficiaries reported being able to take their children to the health center on their own in the case of serious illness. Finally, the greatest impacts were seen among the poorest tercile of households in the program.

Summary Table – Nutrition AM (Yemen)

References and key resources Kurdi, Sikandra; Ghorpade, Yashodhan; Ibrahim, Hosam. 2019. The Cash for Nutrition Intervention in Yemen: Impact Evaluation Study. MENA RP Working Paper 19. Washington, DC and Cairo, Egypt: International Food Policy Research Institute (IFPRI). https://doi.org/10.2499/p15738coll2.133219 Kurdi, Sikandra; Breisinger, Clemens; Ibrahim, Hosam; Ghorpade, Yashodhan; Al-Ahmadi, Afrah. 2019. Responding to conflict: Does “Cash Plus” work for preventing malnutrition?: New evidence from an impact evaluation of Yemen’s Cash for Nutrition Program. IFPRI Policy Brief. Washington, DC: IFPRI. https://doi.org/10.2499/9780896293601 Al-Iryani, Lamis; Kurdi, Sikandra; Palmer-Felgate, Sarah. 2020. Yemen’s ‘Cash for Nutrition’ Programme. ODI Humanitarian Exchange 76. London, England: ODI. https://odihpn.org/magazine/yemens-cash-for-nutrition-programme/

Target Population



based Individual



Monthly; with

additional Quarterly sessions

Home visits and health

center referrals; as

needed

Malnutrition screenings

Infant and young child

nutrition, health, and hygiene

“Cash for Nutrition” program

curriculum


Parents, Peer-to-Peer

Community Health

Educators: Diploma required; Monthly stipend

https://doi.org/10.2499/p15738coll2.133219

https://doi.org/10.2499/9780896293601

https://odihpn.org/magazine/yemens-cash-for-nutrition-programme/

40

Parenting-Focused Accompanying Measures of Cash Transfer Programs

Brazil: Largest home visiting program promotes parenting practices and nurturing care

Programa Bolsa Familia (PBF), a conditional cash transfer program, was launched in 2003 to address high levels of hunger, poverty, inequality and violence that have persisted in Brazil. PBF provided cash transfers to low-income families on the basis of health and education conditions for children under 18 and has been found to be successful in reducing income inequality and hunger in historically underprivileged areas, including among the urban poor. The program currently reaches over 14 million families, or 58 million people, per year and therefore represents the largest CCT in the world. The program aims to break the cycle of poverty by encouraging families to invest in the human capital of their children and empowers beneficiaries by linking them to complementary services including employment training and other social assistance programs. The target groups include poor households with income levels below a certain threshold and includes additional transfers for children under 18.

Parenting Accompanying Measure The Crianza Feliz program, or “Happy Child”, was initially launched in 2016 with strong presidential support as an accompanying measure to improve parenting practices and support early stimulation activities among beneficiaries of PBF and then expanded to non PBF. The program targets Brazil’s poorest households with children under three, or under six for disabled children, and aims to reach two million children once fully scaled. The measure consists of regular home visits by trained personnel in order to help households boost the development of young children through improved parenting practices. The program aims to improve children’s motor coordination and cognitive development through activities that enhance parental engagement with young children. Trained program staff travel to vulnerable communities, sometimes in very isolated and remote areas, to coach parents on how to reduce stress in the household environment and show affection to their children to better support cognitive development. They use locally available materials and model positive play behavior so that parents become more engaged, while raising awareness among parents on the importance of engaging with children to support their cognitive development. The program is adapted from the WHO/UNICEF Care for Child Development parent coaching package, but also builds on many years of experience implementing parenting programs in Brazil and lessons learned from the Jamaica Home Visiting Program (Reach Up). The country is also testing other models of parentings programs, such as the implementation of Jamaica model in the State of Roraima. The program has received international awards for innovation10.

Service Delivery Trained social workers conduct home visits among the beneficiary households and provide referrals for children who require extra assistance or specialized care. The home visits are conducted on a regular basis, including monthly visits for pregnant women and weekly visits during the first three years of the child’s life. Social workers provide feedback to parents and coach families on activities that improve motor coordination and cognitive development of young children. Children in need of extra support are referred to the appropriate specialist, such as physiotherapists, speech or occupational therapists, or registered with local public services. The training for home visitors covers how to plan the visit, develop activities, link children with local services, and what to do in cases of household violence or health issues. Social workers receive training and guidelines from supervisors within each municipality on how to develop and lead appropriate activities for families and help to register them

10 CF received the 2019 WISE award https://www.wise-qatar.org/project/happy-child-program-ministry-citizenship-brazil/

https://www.wise-qatar.org/project/happy-child-program-ministry-citizenship-brazil/

41

with local public services. While their backgrounds vary, home visitors in one intervention area include psychology students at a local university. Hiring processes vary across municipalities, but many municipalities choose to use an internship model to hire students from social areas for a rapid scaling up. Notably, the program is also reaching refugees who have fled ongoing instability in Venezuela.

Institutional Coordination The Citizenship Ministry11 in Brazil serves as the government focal point for coordination and oversight of the Crianza Feliz program. Sectoral ministries for education, health, human rights and culture are key government stakeholders in program design, implementation, and monitoring. An inter-ministerial committee at the federal level designed the permanent training program in order to build capacity of the home visitors. The high-level training is then decentralized to coordinators at the state level and supervisors within each municipality. Municipalities receive financial resources from the federal government in order to train and hire home visitors and payments are based on performance (number of visits conducted). While improving access to services among poor households is one of the priorities of the program, this brings challenges in poor, isolated and marginalized communities that lack access to quality public services. As a result, stronger coordination between health, education, and social assistance sectors can help to better reach the most vulnerable groups including traditional, indigenous communities and the urban poor. The program is also supported by foundations and non-profit organizations, including Brazil’s Fundacao Cecilia Souto Vidigal and the Bernard van Leer Foundation.

Impact Evaluation The impacts of Crianza Feliz have yet to be evaluated, however a three-year experimental evaluation is in place to assess changes in cognition, attachment, and motor development due to the program and is complemented by a process evaluation. An earlier home visit program in Brazil called Primeira Infancia Melhor (PIM), or Better Early Childhood, found mixed results on child development outcomes. PIM involved both weekly home visits to families with children under 3 years old, as well as group meetings for families with children between 3-6 years old. The evaluation compared the school readiness and developmental vulnerability of PIM participants to a comparison group who did not attend any ECD program. It found no significant differences in children’s development at school entry between the two groups but did reduce gaps in equity of outcomes within the PIM group (Goncalves et al., 2019). Preliminary results from a long-term evaluation of PIM show the program also reduced youth crimes (Jaitman et al.). One study found that PIM reduces the number of deaths due to external causes by 0.68 deaths per 1,000 children, in municipalities with program exposure of at least seven years (Ribeiro et al., 2018).

Summary Table – Parenting AM (Brazil)

Target Population


Strategies Front-line Workers Group-

based Individual

visits Other Poor

households with

children under 3

-- Home visits; Monthly then weekly (after

birth)

--

Parenting practices, early

stimulation, motor and cognitive development

Care for Child

Development


to Parents, Materials

Trained social workers, including students

11 < https://www.gov.br/cidadania/>

https://www.gov.br/cidadania/

42

References and key resources Anderson, Jenny. 2018. “Brazil’s audacious plan to fight poverty using neuroscience and parents’ love.” Quartz. https://qz.com/1298387/brazils-wildly-ambitious-incredibly-precarious-program-to-visit-every-poor-mother-and-change-their-childrens-destiny/

Cikovic, Stevan. 2019. “Bolsa Familia in Brazil.” Centre for Public Impact. https://www.centreforpublicimpact.org/case-study/bolsa-familia-in-brazil/

Girade, Halim Antonio. 2018. “Criança Feliz’: A programme to break the cycle of poverty and reduce the inequality in Brazil.” Early Childhood Matters. https://bernardvanleer.org/app/uploads/2018/06/2.1-Crianc%CC%A7a-Feliz.pdf

Goncalves, Tonantzin; Duku, Eric; Janus, Magdalena. 2019. Developmental health in the context of an early childhood program in Brazil: the ‘Primeira Infancia Melhor’ experience. Reports in Public Health 35(3). http://www.scielo.br/pdf/csp/v35n3/1678-4464-csp-35-03-e00224317.pdf

Graham, Jack. 2017. “Brazil is helping its poorest children get an equal start in life.” Apolitical. https://apolitical.co/solution_article/brazil-helping-poorest-children-get-equal-start-life

Andréia Peres e Marcelo Bauer. 2018. From science to practice – Programs supporting child development in Latin America. São Paulo (Portuguese) https://bernardvanleer.org/app/uploads/2018/12/Da-Ci%C3%AAncia-%C3%A0-Pr%C3%A1tica_web_Final-compressed2.pdf

Ribeiro, Felipe Garcia, Braun, Gisele, Carraro, André, Teixeira, Gibran da Silva, & Gigante, Denise Petrucci. 2018. An empirical assessment of the Healthy Early Childhood Program in Rio Grande do Sul State, Brazil. Cadernos de Saúde Pública, 34(4). https://doi.org/10.1590/0102-311x00027917

https://qz.com/1298387/brazils-wildly-ambitious-incredibly-precarious-program-to-visit-every-poor-mother-and-change-their-childrens-destiny/

https://qz.com/1298387/brazils-wildly-ambitious-incredibly-precarious-program-to-visit-every-poor-mother-and-change-their-childrens-destiny/

https://www.centreforpublicimpact.org/case-study/bolsa-familia-in-brazil/

https://www.centreforpublicimpact.org/case-study/bolsa-familia-in-brazil/

https://bernardvanleer.org/app/uploads/2018/06/2.1-Crianc%CC%A7a-Feliz.pdf

http://www.scielo.br/pdf/csp/v35n3/1678-4464-csp-35-03-e00224317.pdf

https://apolitical.co/solution_article/brazil-helping-poorest-children-get-equal-start-life

https://bernardvanleer.org/app/uploads/2018/12/Da-Ci%C3%AAncia-%C3%A0-Pr%C3%A1tica_web_Final-compressed2.pdf

https://bernardvanleer.org/app/uploads/2018/12/Da-Ci%C3%AAncia-%C3%A0-Pr%C3%A1tica_web_Final-compressed2.pdf

https://doi.org/10.1590/0102-311x00027917

43

Burkina Faso: Social and behavior change communication enhances parenting practices

In 2015, an unconditional cash transfer (UCT) called Burkin-Naong-Sa-Ya was launched in Burkina Faso in response to high rates of poverty and child malnutrition. The UCT was introduced in regions with the highest prevalence of chronic poverty and under-5 chronic malnutrition (height-for-age) in the country. As of 2019, the project reached 550,000 beneficiaries, primarily women, and is expanding to additional regions and projected to reach more than one million beneficiaries by 2024. The program targets groups most vulnerable to malnutrition, notably households with young children, pregnant women and lactating mothers in order to increase food consumption, access to health and nutrition services. Additionally, it supports women to participate in productive activities and aims to increase the resilience of poor households against negative shocks.

Parenting Accompanying Measure The parenting accompanying measure aims to improve awareness and behaviors at the household level that promote human development including child growth and nutrition. Accompanying measures focus on demand-side mechanisms to improve child welfare and promote investment in children’s human capital using a social and behavior change communication (SBCC) approach. SBCC services are designed to raise awareness, change attitudes and behaviors, and enhance knowledge to encourage adoption of positive parenting practices surrounding child health, nutrition and psycho-social development that in turn improve child development. The approach helps to encourage households to provide proper nutrition for young children and invest in schooling and healthcare. While targeted towards pregnant women, caregivers, and mothers with young children, the program aims to identify and involve all community members including decision makers, opinion leaders, and other household and community members who influence the behavior of the target group. Therefore, monthly village assemblies bring together a broader range of community stakeholders. Approximately 90 percent of women beneficiaries participate in group education activities focused on early childhood development.

Service Delivery Community facilitators (FACOM) lead the SBCC activities through group education sessions, household visits, and counseling on nutrition, healthcare and sanitation to beneficiary households in participating communities. Starting from project registration, beneficiary households receive information on project objectives and commit to taking positive actions and behaviors for human capital investment. The home visits provide information to parents and promote behavior change surrounding child health, nutrition, and psycho-social development. The FACOM train and supervise Mother Leaders, who are each assigned to a parental education group of 25-30 beneficiaries and reinforce the SBCC activities and behaviors. Beneficiaries are also encouraged to participate in education, information, and communication (IEC) sessions on topics such as good nutrition, breastfeeding, basic healthcare and sanitation.12 IEC sessions are open to both beneficiary and non-beneficiary households and the topics vary by age: nutrition for pregnant women and mothers with children 0-2 years old, community-based promotion of cognitive development through improved parenting skills for children 2-5 years, education for children 5-15 years, and economic capacity and empowerment for women. The package of SBCC interventions is adjusted according to the existing capacity and experience in each district.

12 The IEC sessions for mothers of children ages 0-2 cover antenatal care, dietary intake of pregnant and lactating women, timely initiation of breastfeeding, exclusive breastfeeding for the first 6 months, continued breastfeeding up to 24 months, appropriate complementary feeding from 6 months onward, intake of micronutrient-rich foods, and food hygiene practices.

44

Institutional Coordination The project is implemented at the community level by the FACOM, who are hired by the project and work in collaboration with NGOs that coordinate with existing structures and programs to deliver a wide range of services. Frontline workers and existing structures include health outreach workers, agricultural extension workers, social protection agents, other public service providers, and local authorities. In areas where the World Bank’s Reproductive Health Project operates, health outreach workers are primarily used to support access to health services. The Ministry of Health requires that the UCT program collaborates with community health workers and Community-Based Executing Organizations (OBCE) who are trained by the District Health Officers, as well as capacity-building NGOs to implement community-based activities. Utilizing existing services helps to enhance access for beneficiaries and other community members while avoiding the creation of parallel delivery structures. Partnerships also help reduce duplication, and the program coordinates with UNICEF on training modules and communication material pertaining to the infant and young child feeding (IYCF) approach. Lastly, rather than providing direct nutrition support, the project coordinates with existing community-based nutrition activities to link cash transfer beneficiaries with food and nutrient supplementation and distribution services.

Impact evaluation An impact evaluation is currently underway to measure the added benefits of the accompanying measures to improve parenting, health and nutrition practices, beyond the impacts of the cash transfers. It will compare the child development outcomes of varying levels of intensity and frequency of accompanying measures, to the “cash only” intervention. The results will be used to inform potential scale-up of the cash plus program as a pillar of the national social safety net for reducing chronic poverty and building household resilience.13 The impact evaluation is supported by the Strategic Impact Evaluation Fund (SIEF) of the World Bank and builds on earlier research that looked at the differential impacts of CCTs and UCTs on health care usage and school enrolment. In this case, CCTs boosted preventive health care visits for children by more than 40% compared to baseline, and UCTs and CCTs both increased school enrollment, although CCTs were significantly more effective at improving enrollment among excluded children (Akresh et al., 2016).

Summary Table – Parenting AM (Burkina Faso)

Target Population



based Individual



Monthly Home Visits; Weekly

Village assembly; Monthly

Parenting to promote nutrition, child health, and

psycho-social development

UNICEF KFP, SUN, Learning

Through Play


to Parents, Peer-to-Peer

Community Facilitators: No minimum education; Voluntary


Akresh, Richard; De Walque, Damien B. C. M.; Kazianga, Harounan. 2016. Evidence from a randomized evaluation of the household welfare impacts of conditional and unconditional cash transfers given to mothers or fathers. Policy Research working paper; no. WPS 7730; Impact Evaluation series. Washington, D.C.: World Bank Group.

Ministère de la Femme, de la Solidarité Nationale et de la Famille. 2017 Directives aux facilitateurs communautaires et animatrices pour la mise en œuvre des mesures d’accompagnement pour le développement humain.

13 A brief overview can be found at the SIEF website https://www.worldbank.org/en/programs/sief-trust-fund/brief/evaluations-early-childhood-development

https://www.worldbank.org/en/programs/sief-trust-fund/brief/evaluations-early-childhood-development

https://www.worldbank.org/en/programs/sief-trust-fund/brief/evaluations-early-childhood-development

45

Colombia: Mother leaders deliver psychosocial and nutritional accompanying measures

Children living in the lowest income households in Colombia face substantial challenges for child development and a high incidence of early childhood anemia. Significant gaps in cognitive and linguistic development between children from different socioeconomic groups emerge as early as 12 months and widen substantially by age three. Over 30 percent of children from the lowest socioeconomic category are anemic and stunting prevalence is 15 percent of children 12-24 months. In 2000, Familias en Acción (FA) was launched as a temporary poverty relief program that was subsequently scaled up and renamed Mas Familias en Accion (MFA) starting in 2011. The CCT reaches poor households with children under 18, as well as displaced and indigenous families. Health conditions require children under seven to regularly attend growth and development check-ups and participate in vaccination programs, and for their mothers to attend educational workshops on nutrition, hygiene and contraception. The education component requires children aged 7-17 to attend school for at least 80% of the school year. In 2013, MFA began coordinating with the early childhood development government initiative De Cero a Siempre, which reflects the program’s evolution from emergency response to the primary national program for poverty reduction and child health. As of 2015, it covered 2.7 million families in over 1,000 municipalities.

Parenting Accompanying Measure A small-scale program assessed the potential of a parenting accompanying measure combined with the MFA cash transfer program to improve behavior around health, child stimulation, and nutrition. The program began in 2010 and was implemented for 18 months. It included both a psychosocial stimulation component that adapted the successful Jamaican home visiting model to the Colombian sociocultural context, as well as a nutrition component that included micronutrient supplementation and awareness-raising on improved nutrition practices. Home visits on these topics intended to improve the quality of maternal-child interactions and to assist mothers to participate in developmentally appropriate learning activities largely centered around daily routines. The micronutrient supplementation was based on a formula used to treat childhood anemia and was provided for all children in the household under six years old.

Service Delivery Both the psychosocial and nutritional components of the parenting accompanying measure were delivered by mother leaders who conducted the home visits over an 18-month period. In the CCT program, mother leaders are elected from among the program beneficiaries and act as liaisons between groups of beneficiary families and local program officials. The home visits were made weekly and included demonstrations of appropriate play activities using low cost or homemade toys. Mother leaders also distributed micronutrient supplements to households every two weeks and monitored their use. The mother leaders were trained for several weeks by experienced social workers, who served as mentors and provided ongoing support and performance monitoring. Quality assurance was provided through regular bulletins on best practices and short text messages each month to reinforce key advice including to listen to and praise the mothers, and mother leaders were encouraged to call the mentors for advice when necessary. The mentors also received six weeks of pre-service training and visited communities every 2-3 months to monitor program implementation and provide support.

Institutional Coordination The CCT is managed and implemented by a national coordinating unit but is decentralized to regional coordinating units at the department level that liaise with national and municipal governments. Program monitoring is based on a comprehensive system that covers beneficiary registration, compliance with conditionalities, transfer payments, and case management. The program works in coordination with other

46

initiatives including in the areas of children and youth, food security, productive inclusion, and housing. The accompanying measure relied on the existing infrastructure of the CCT program to pilot an early childhood development intervention that integrated both a psychosocial and nutritional component. Therefore, the accompanying measure relied on the existing social welfare systems with established administrative capacity and local community networks.

Impact Evaluation Evidence shows that the CCT improve health outcomes and that adding accompanying measure for nutrition and child stimulation had varying effects on child health and development. The CCT program Familias en Acción has been found to increase food consumption, notably protein-rich foods, and height-for-age among the youngest and poorest children and to reduce symptoms of diarrhea and increased rates of vaccination (Attanasio et al. 2006). Other evaluation measured the impact of providing psychosocial stimulation, nutritional supplements and both of them. Findings showed that the stimulation interventions improved cognitive and language outcomes, however micronutrient supplementation had no significant effect (Attanasio et al. 2014). The improved cognitive outcomes were largely driven by increased parental investment in both time and resources as reinforced by the home visits. At the two-year follow-up, the cognitive improvements were not sustained (Andrew et al., 2018). This may have been driven by inadequate resources which contributed to poor program implementation, or the lack of sustained changes in parental behaviors after the intervention concluded.14

Summary Table – Parenting AM (Colombia)

Target Population



based Individual

visits Other

Mother of children 12-

24 -- Home visits;

Weekly

Nutrition Suppleme

nt

Psychosocial stimulation,

nutrition, mother-child interaction

Adapted from Reach Up,

with nutrition component


to parents, Materials

Mother Leaders: Basic

reading comprehension; Monthly stipend


Andrew, Alison; Attanasio, Orazio; Fitzsimons, Emla; Grantham-McGregor, Sally; Meghir, Costas; Rubio-Codina, Marta. 2018. Impacts 2 years after a scalable early childhood development intervention to increase psychosocial stimulation in the home: a follow-up of a cluster randomized controlled trial in Colombia. PLOS Medicine, 15(4): e1002556.

Attanasio, Orazio; Fernández, Camila; Fitzsimons, Emla; Grantham-McGregor, Sally; Meghir, Costas; Rubio Codina, Marta. 2014 Using the infrastructure of a conditional cash transfer program to deliver a scalable integrated early child development program in Colombia: cluster randomized controlled trial. BMJ; 349: g5785

Attanasio, Orazio, and Alice Mesnard.2006. “The Impact of a Conditional Cash Transfer Programme on Consumption in Colombia.” Fiscal Studies 27, no. 4: 421–42.

Medellin, Nadin; Prada, Fernando Sanchez. 2015. How does Mas Familias en Accion work? Best practices in the implementation of conditional cash transfer programs in Latin America and the Caribbean. Technical Note IDB-TN-884. Inter-American Development Bank.

Segura-Perez, Sofia; Grajeda, Ruben; Perez-Escamilla, Rafael. 2016. Conditional cash transfer programs and the health and nutrition of Latin American children. Rev Panam Salud Publica 40(2): 124-37.

14 See https://www.povertyactionlab.org/evaluation/impact-cognitive-stimulation-and-nutritional-supplements-early-childhood-development for additional information on the original evaluation and follow-up study.

https://www.povertyactionlab.org/evaluation/impact-cognitive-stimulation-and-nutritional-supplements-early-childhood-development

https://www.povertyactionlab.org/evaluation/impact-cognitive-stimulation-and-nutritional-supplements-early-childhood-development

47

Madagascar: Behavioral nudges increase parental investment in the early years

Widespread malnutrition, limited opportunities for early learning, and inadequate child stimulation, care and parenting practices have had severe consequences for child development in Madagascar. Close to 80 percent of the population live below $1.90 per day and nearly half of children under 5 years of age suffer from stunting. Recurrent climate shocks further exacerbate food insecurity and malnutrition. Malagasy mothers face high levels of malnutrition and maternal mortality and school completion rates are low, which contributes to the intergenerational transmission of poverty. The Human Development Cash Transfer Program (HDCT) was launched in 2015 to build the human development of young children in Madagascar through education conditions and improved parenting and nutrition practices. As of 2018, the program covers 44,800 households and 224,000 beneficiaries. The cash transfer is composed of a flat amount for all beneficiary households and a flexible amount if children ages 6-12 attend primary school. Children under six years old are required to attend health check-ups and their parents are targeted with accompanying measures.

Parenting and Behavioral Nudges Accompanying Measure The accompanying measure consists of monthly parenting training sessions as well as behavioral nudges on pay-day sessions, both of which are led by mother leaders. The mother leaders are elected from among the cash transfer beneficiaries in each village and are trained to serve as voluntary community leaders and local program organizers. The pay-day sessions use behavioral supports, or “nudges”, to strengthen self-affirmation and financial planning of beneficiaries and remind families of the messages from the group parenting sessions on healthy development. Program design involved in-depth field testing with behavioral psychologists and economists to develop a set of nudges that promote women’s empowerment including financial planning, parenting, and child development. The accompanying measure targets recipients of the cash transfer with children under 6 years old and has been adapted for use in Madagascar’s ongoing productive safety net program (PSNP) through a model of mobile childcare (mobile creche). Beyond the parenting accompanying measures, the program also enhances nutritional behaviors and access to key nutrition services during pregnancy and early childhood.

Service Delivery The accompanying measures are primarily delivered through interactive and participatory group sessions led by mother leaders for beneficiary women in each village. The monthly parenting sessions bring together a regular group of 20-25 beneficiary mothers to sing, dance, and engage in other interactive activities to promote discussion in topics related to child development. The parenting sessions take place in “areas of well-being” (Espaces de Bien-Être) which are centrally located within each village and provide a comfortable and respectful space for beneficiary parents to gather with their children. Additionally, while beneficiaries wait at the pay points to receive the cash transfer payments every two months, small groups of mothers join 30-minute sessions to reflect on their goals, opportunities, and priorities through self-affirmation and financial planning behavior change activities. Activities like drawing, discussions, and games “nudge” participants to reflect on their family’s situation and commit to investing in the early years. The delivery of nudges at the time of cash payments directly links the additional income with an opportunity to purchase items beneficial to child development and other positive financial behaviors, such as saving or other investment decisions, and enhance outcomes such as dietary diversity, food quality, hygiene, or productive activities. Mother leaders receive training on topics such as leadership, citizen engagement, early childhood stimulation, nutrition, family planning and health practices.

Institutional Coordination International, national, and non-governmental organizations support various aspects of the cash transfer and parenting accompanying measure. The HDCT is implemented by the Social Fund for Development (FID) and the

48

Ministry of Population, Social Protection and Promotion of Women (MPSPPW) within the framework of the National Social Protection Policy. Complementarity with the national policy helps to facilitate linkages with community-based nutrition programs, health services, and agricultural extension services. Furthermore, the National Nutrition Policy and National Action Plan highlight key areas of intervention and align the efforts of various stakeholders to support improved nutrition particularly during the early years. The National Nutrition Office (ONN) and the Ministry of Education help to meet increased demand for health and education services while improving service quality. ONN also works closely with the HDCT program to ensure that both groups reinforce the same messages for behavior change surrounding improved nutrition practices. UNICEF advised on the “Key Family Practices (KFP)” curriculum development for the Mother Leaders. Finally, ideas42 is the primary partner working alongside the World Bank to design and implement the behavioral interventions and conduct impact evaluations for the accompanying measure.

Impact Evaluation Ongoing impact evaluations are measuring the effects of the behavioral nudge intervention that are evident above and beyond the impacts of the cash transfers.15 Midline results have shown substantial positive impacts of the behavioral nudges on child human capital outcomes. Among groups receiving only cash, spending on education and school attendance increased, however grade advancement did not; and food consumption, long-term food security, and children’s language development improved. With the addition of the parenting and behavioral measures including the role of the mother leaders, grade advancement increased and uptake of improved parenting behaviors, a reduction in food insecurity, enhanced dietary diversity, and higher language and cognitive skills among children were further enhanced by one half to two-thirds the size of the effect of cash alone.

Summary Table – Parenting AM (Madagascar)

Target Population



based Individual

visits Other

Mothers of children under 6

Monthly -- Pay-day ‘Nudges’

Parenting practices, child

development, self-affirmation,

financial planning

UNICEF KFP; WB and

ideas42 behavioral elements


to Parents, Payday Nudges

Mother Leaders:

No minimum education; Voluntary


World Bank. 2018. Madagascar – Cash and Change: The Human Development Cash Transfer Program uses behavioral nudges to strengthen mother’s self-affirmation and planning (English). Washington, D.C.: World Bank Group.

World Bank. 2018. Behavioral nudges for cash transfer programs in Madagascar (English). Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/885331517847021570/Behavioral-nudges-for-cash-transfer-programs-in-Madagascar

15 Additional information is available on the SIEF website at https://www.worldbank.org/en/programs/sief-trust-fund/brief/evaluation-of-a-behavioral-approach-to-improve-outcomes-in-early-childhood



https://www.worldbank.org/en/programs/sief-trust-fund/brief/evaluation-of-a-behavioral-approach-to-improve-outcomes-in-early-childhood

https://www.worldbank.org/en/programs/sief-trust-fund/brief/evaluation-of-a-behavioral-approach-to-improve-outcomes-in-early-childhood

49

Mexico: Integrated programs enhance early stimulation, parenting, timely detection and care

Large segments of the Mexican population face food insecurity and nutrition challenges, and approximately 44 percent live below the national poverty line. The overall stunting rate for children under five is approximately 12 percent nationwide, however this reaches 44 percent in rural areas and among indigenous populations. The poorest states in Mexico, including Chiapas, Guerrero, and Oaxaca, have stunting rates of over 20 percent (World Bank, 2018). Mexico’s CCT Program, PROSPERA, was launched in 1997 as a cash transfer for poor families with young children to support access to health and nutrition services and schooling.16 The CCT reached 6.1 million families based on conditions tied to the use of preventive health and nutrition services and school attendance. The experience of PROSPERA showed how a longstanding nation-wide safety net program evolved into a cross-ministerial effort to improve the nutritional status and cognitive development of children. Unfortunately, PROSPERA was cancelled in 2019 without a good justification or acknowledge of its achievements.

Program 1: Promotion and Care of Child Development (PRADI) Parenting Accompanying Measures Developed in 2013, Promotion and Care of Childhood Development (PRADI) was a component of PROSPERA that aimed to improve motor and cognitive skills and socio-emotional development for families with children under 5. It focused on improved child rearing practices based on early detection, timely care and education at the community level (Figure 2). The detection and timely care components supported early stimulation for children living in poverty and strengthened referral networks and follow-up care for children with developmental delays. The community education component was less established but aimed to reach pregnant women and children under 3 to improve parenting knowledge and practices, increase childcare quality, improve motor, cognitive, and social-emotional development of children, and strengthen healthy pregnancy and healthy child programs.

Service Delivery PRADI had three main components which were delivered separately: (i) an early detection and referral for children who were screened for delays in child development; (ii) a parenting component which included group meetings to promote positive parenting from pregnancy to age 3; and (iii) coordination with existing programs for group care. The early detection and timely care component of PRADI was implemented and supervised by a large network of psychologists with clinical experience. The Child Development Evaluation (CDE) Test screening tool was used to evaluate child development including any developmental delays. Health center personnel including doctors and nurses were trained to perform the test, and a supervision model was developed in 2013 to ensure the test was correctly implemented. Starting in 2014, financing was provided to states for the creation of Regional

16 PROSPERA has since been converted into a Scholarship Program under the Ministry of Education. The only conditionality is school enrollment. The conditionalities related to health, nutrition, and school attendance have been dropped.

Figure 1. Child development activities under the PRADI component of PROSPERA.

50

Centers for Child Development (CRDI) to provide comprehensive care of children at risk of developmental delays, including diagnosis, management, referral, research, training, and coordination of the Childhood Development Strategy.

Institutional Coordination Through the National Commission on Social Protection and Health (CNPSS), children who were not covered by contributory social security received protections through the health component of the PROSPERA program. Beneficiaries included families who were enrolled in the non-contributory health insurance program, Seguro Popular. The National Development Plan and health sector program further reinforced the importance of early childhood development. The Centro Nacional para la Salud de la Infancia y la Adolescencia within the Children’s Hospital of Mexico, a public health institution, oversaw implementation of PRADI. CNPSS financed the development of the CDE test, supported curriculum development for the community education component of PRADI and financed the CRDI.

Impact Evaluation PROSPERA’s evolution over the last 20 years was informed by impact and process evaluations conducted regularly by external and national evaluators. Impact evaluations have found that the CCT increased secondary school enrolment rates, improved preventive care and health outcomes among children under 5, increased the number of health center visits during the first trimester of pregnancy, and increased household food expenditures (Parker et al., 2017). There was no impact evaluations of the PRADI program, although there was an impact evaluation that assesses community and individual delivery modalities (Vargas Lopez et al, no date).

Summary Table – Parenting AM (Mexico – PRADI)

Target Population



based Individual

visits Other

Families with

children under 3

Monthly

Early detection,

referral, links to services; as needed

--

Child-rearing practices,

detection and timely care

Own; community

workers trained to facilitate

Demonstrations, Feedback to

Parents, Peer-to-Peer, Father

Inclusion

Education in field of practice; 2

years’ work on child health

Program 2: Educacion Inicial (EI) Parenting Accompanying Measure Educación Inicial (EI) is a program designed and implemented by the National Council for Education Development (CONAFE) that provides knowledge, skills, training, and opportunities to practice for parents living in poor and isolated rural communities in Mexico with limited access to preschool programs. EI included weekly activities to engage parents in group sessions, and each weekly session was based on an early childhood topic such as hygiene and nutrition, motor development, psycho-social development, and early childhood stimulation to promote cognitive and language development. The content also included age-specific issues such as care during pregnancy and responsive feeding. The curriculum was developed by a team of psychologists, education experts, and child development specialists and makes links to behavior change, child development, and cognitive stimulation. Targeting and benefits of EI were not directly linked to the PROSPERA CCT.

Service Delivery The EI program was delivered by promotoras who engage parents face-to-face in two-hour group settings on a weekly basis. The sessions occured at a centrally located structure for groups of approximately 20 women. Sessions were designed to improve parenting practices and strengthen early childhood development based on

51

reinforcement of the child-caregiver relationship. All pregnant women and caregivers of children aged 0 to 4 were invited to attend the session. Parents work with promotoras, who were selected at the community level, to determine the time and location of the weekly sessions. They also received materials and intensive supervision and feedback. They were encouraged to use different strategies for facilitating the sessions based on the target groups: pregnant women, infants 0-1 years old, children 1-3 years old, mothers, and fathers. Parents were encouraged to make toys at home and to use existing resources to engage with and educate their children. One year of program consisted of 26 sessions for mothers, fathers and caregivers; 5 sessions for fathers; 18 sessions focused on children; 8 sessions for pregnant women; and 5 concluding sessions. For quality assurance, promotoras received annual training at the beginning of each operating cycle, methodological and material support for the sessions, printed and other materials, and supervision and feedback with oversight provided by local supervisors and program coordinators.

Institutional Coordination EI is a federal program that operates as an independent and decentralized unit within the Secretary of Education and implemented by CONAFE. The system and process of EI program implementation is standardized across states, however quality of program delivery varies.

Impact Evaluation An evaluation of the EI program found that the group-based parenting program improved child cognitive outcomes particularly for children living in indigenous communities and in the lowest quintile of child development when the families received income support and promotion to participate on the sessions from the CCT program (Fernald et al., 2017).

Summary Table – Parenting AM (Mexico – EI)

Target Population



based Individual

visits Other Pregnant

women and caregivers of children

under 3

Weekly -- --

Parenting practices, support to child-caregiver

relationship

Developed by team of Mexican

specialists


Parents, Peer-to-Peer, Materials

Promotoras: Primary

education (for basic literacy);

Voluntary


Fernald, Lia et al. 2017. Promoting child development through group-based parent support within a cash transfer program: experimental effects on children’s outcomes. Developmental Psychology. 53(2), 222–236

O’Shea-Cuevas, Gabriel; Rizzoli-Cordoba, Antonio et al. 2015. Social protection system in health for early detection and care of child developmental problems in Mexico. Boletin Medico del Hospital Infantil de Mexico.

Vargas Lopez, Guillermo; Medrano Loera, Geronimo; Ibarra Espineira, Yulene Maria; Cenobio Narcizo, Francisco Javier; Reyes Morales, Hortensia; Garduno Espinosa, Juan. No date. Informe final de la implementacion de la intervencion: Modelo de Promocion y Atencion del Desarrollo Infantil Motor, Cognitivo y Socio-emocional Familiar (PRADI). Hospital Infantil de Mexico.

Parker, Susan; Todd, Petra. 2017. Conditional Cash Transfers: The Case of Progresa/Oportunidades. Journal of Economic Literature. 55(3), 866-915. https://doi.org/10.1257/jel.20151233

World Bank. 2018. Mexico - Expanding an Icon’s Mandate: Moving Beyond Access to Health and Nutrition to Focus on Cognitive Development in the PROSPERA Conditional Cash Transfer Program (English). Washington, D.C.: World Bank Group.

https://doi.org/10.1257/jel.20151233

52

Niger: Incorporating psycho-social stimulation in response to household needs

Few countries face greater early childhood development challenges than Niger, as indicated by low levels of human development and high rates of poverty, population growth, and malnutrition. Children under five make up a quarter of the population and 44 percent are stunted due to chronic malnutrition; in addition, preschool access and primary school enrolment levels are very low. A large share of Niger’s population suffers from chronic food insecurity, which is exacerbated by recurrent, countrywide droughts. The Government of Niger, together with the support of the World Bank, launched the Niger Safety Nets project in 2012 to combat poverty and food insecurity in the five poorest regions of the country. The project provides cash transfers of about US$20 a month to the poorest households over a period of 24 months. As of 2017, the program has been implemented in over 1,500 villages and has reached over 143,000 households and 1 million direct project beneficiaries.

Parenting Accompanying Measure The cash transfer program includes a behavioral change component (volet comportemental) which promotes parenting practices that support early childhood development. The parenting program was developed based on core topics of UNICEF’s key family practices package including health, nutrition, hygiene and sanitation, and family planning (Table 1). In response to findings from an early pilot program, new modules on nutrition and psycho-social stimulation were added to promote a holistic approach to child development and better align with the objectives of the safety nets project. The new modules were developed to promote cognitive and socio-emotional development based on local context and needs. An implementation manual covers the curriculum content, implementation modalities, supervision and quality control, and monitoring and information systems to ensure the intervention is well structured, standardized, and scalable. It adopts a “positive deviance” approach to support and build on existing good practices in each community. The target population is very poor women in chronically poor households with children under five years. While participation in the volet comportemental activities is not required to receive the monthly cash transfer, over 90 percent of beneficiaries regularly participate.

Service Delivery The parenting intervention is delivered by local NGOs and community educators through monthly home visits and group meetings over a period of 18 months. Beneficiary households participate in three activities per month: (i) a village assembly delivered by NGO field staff; (ii) a small group meeting led by a community educator; and (iii) a home visit from the same community educator. The monthly village assembly is organized for approximately 50 beneficiary households but is also open to non-beneficiary households in those villages, whereas the monthly small meetings are organized for groups of 25 beneficiaries. The monthly home visits further support behavior changes through one-on-one delivery and reinforcement of the key family practices and additional modules. Community educators live in the villages where they work and are each assigned to 25 families within one village.

Key Family Practices Additional Modules • Handwashing and hygiene • Exclusive breastfeeding for first six months • Complementary feeding after six months • Child malnutrition • Declaration of birth at the civil registry office • Protecting children from diseases • Health visits for children at first sign of illness • Management of pregnancy, childbirth and birth spacing

• Language stimulation • Playing with children • School readiness, enrolment and attendance • Brain development and sleep management • Discipline, punishment and conflict

management • Attachment and socio-emotional development

Table 1. Modules of the behavioral change component to promote improved parenting practices in Niger

53

They receive two weeks of initial training followed by two additional two-week training periods throughout program implementation. Each NGO field worker oversees 10-15 villages with oversight provided by quality management and specialized staff, and NGO field staff serve as mentors to community educators to build their capacity and improve performance. As of 2017, over 3,300 community educators had been trained in delivery of the accompanying measure, which reaches 1500 villages and 87,000 beneficiary households.

Institutional Coordination The Government of Niger is responsible for overall management and coordination of the cash transfer program and accompanying measure. The program is managed out of the Niger Safety Nets Unit (Cellule Filets Sociaux) located in the Office of the Prime Minister. Implementation of the accompanying measure on the local level is contracted out to sixteen different NGOs that also implement the cash transfer program. Building on the UNICEF key family practices for the curriculum, the World Bank and Early Learning Partnership (ELP) supported the development of the implementation manual (Guide technique du volet comportemental). Overarching coordination for the accompanying measure was divided between one national coordinator, eight regional representatives, and governmental field operator per commune. Implementation costs are estimated at USD 86 per beneficiary household and USD 14 for indirect oversight costs (Barry et al., 2017).

Impact Evaluation Impact evaluations have found that the parenting accompanying measure improved parenting practices and behavior and child socio-emotional skills. The volet comportemental improved parenting practices including increased uptake of exclusive breastfeeding and complementary feeding which improved child nutrition and food security. Child stimulation improved and there was a reduced practice of harsh discipline, which may have contributed to the significant and positive impacts on children’s socio-emotional development. Spillover effects to non-beneficiaries were also noted. However, the intervention had no impact on cognitive development or anthropometric outcomes in the short term (Premand et al., 2020). A process evaluation was also recently completed (Bouckaert et al., 2018).

Summary Table – Parenting AM (Niger)

Target Population

Delivery Modality Topics Curricu

lum SBCC

Strategies Front-line Workers Group-based

Individual visits Other

Poor women with children

under 5 Monthly Home visits;

Monthly Village

assembly

Parenting to promote health, nutrition, hygiene, family

planning, psycho-social development

Adapted from

UNICEF KFP

Feedback to Parents,

Media, Peer-to-Peer

Community educators: No minimum

education; monthly stipend


Barry, Oumar; Maidoka, Ali Mory; Premand, Patrick. 2017 Promoting positive parenting practices in Niger through a cash transfer programme. Early Childhood Matters – Bernard van Leer Foundation. https://bernardvanleer.org/ecm-article/2017/promoting-positive-parenting-practices-niger-cash-transfer-programme/

Bouckaert Kimberley, Honkuy Stanislas, Ibrahim Aichatou, Premand Patrick, Ruel Bergeron Julie. 2018. Evaluation de processus de la mise en œuvre du volet comportemental du Projet Filets Sociaux au Niger. Washington, DC : Banque Mondiale.

Stoeffler, Quentin; Mills, Bradford F.; Premand, Patrick. 2016. Poor households' productive investments of cash transfers: quasi-experimental evidence from Niger (English). Policy Research working paper; no. WPS 7839; Impact Evaluation series. Washington, D.C.: World Bank Group.

Premand, Patrick; Barry, Oumar. 2020. Behavioral Change Promotion, Cash Transfers and Early Childhood Development: Experimental Evidence from a Government Program in a Low-Income Setting. Policy Research Working Paper;No. 9368.

https://bernardvanleer.org/ecm-article/2017/promoting-positive-parenting-practices-niger-cash-transfer-programme/

https://bernardvanleer.org/ecm-article/2017/promoting-positive-parenting-practices-niger-cash-transfer-programme/

54

Peru: A home visiting service in poor, rural and marginalized communities

Over the last 25 years, Peru has experienced strong and inclusive economic growth, accompanied by job creation and poverty reduction. However, disparities persist, particularly among rural populations, which face higher poverty rates, lower access to services, and lower levels of human capital. While Peru has achieved success in reducing the prevalence of stunting among children under five, stunting and anemia rates remain higher among children in poor and rural areas. In 2005, the CCT program Juntos (“Together”) was launched to capitalize on the country’s economic growth in order to support human capital development and break the inter-generational cycle of poverty. The program aims to improve access to health and nutrition, education, and protection services for pregnant women and young children. As the first cash transfer program in Peru, Juntos provides income support to parents to help them access basic services for their children. Target districts are selected based on district-level poverty rates. Conditionalities have varied over time but generally include primary school attendance and regular health care visits for pregnant women and mothers with children under five.

Parenting Accompanying Measure The ECD program Cuna Más was established as a complementary intervention to Juntos to improve the holistic development of young children, enhance childrearing knowledge and practices, and strengthen attachments between caregivers and children. Since 2012, the program has operated through a daycare service and a home visiting service. The daycare service provides comprehensive care for children between 6 and 36 months in marginalized urban areas and covers health, nutrition, safety, protection, play, and learning. The daycare service built on and standardized existing Wawa Wasi daycare centers. Since the program was established, Cuna Mas has primarily expanded coverage through the home visiting service that operates in rural areas with high rates of poverty and malnutrition, primarily in rural areas. It targets pregnant women and primary caregivers of children under three. As of 2019, Cuna Mas reached 160,000 children and families across both services, including over 105,000 children through the home visiting service. The home visiting curriculum promotes increased and higher quality adult-child interactions and learning through play. The three areas of program intervention focus on ‘family life’ which includes support to caregivers to promote learning and play in daily activities, ‘learning through play’ which used structured play to promote the development of language, fine motor and cognitive skills, and ‘tell me a story’ which encourages vocabulary and language development using picture books (Araujo et al., 2018).

Service Delivery The home visiting service is conducted at the community level for individual mothers, caretakers, and pregnant women. Specialists train regionally based professionals, who in turn support volunteer community-level actors known as facilitadoras who conduct the home visits. Facilitadoras observe caregiver routines and monitor child development and promote positive care practices for ten families. Each community selects a local management committee (CG) to support operations under the oversight of local authorities or community-based supervisory councils. CGs and local communities select the volunteer facilitadoras who make weekly, hour-long visits to participating families. Facilitadoras receive a monthly stipend of approximately US$115 for the home visits and also co-lead group socialization and peer learning sessions for participating families alongside technical staff. The group sessions reinforce information learned during the home visits and motivate caregivers to further develop their knowledge. Topics covered during the home visits include play, communication, child stimulation, oral hygiene, handwashing, micronutrients, exclusive breastfeeding, complementary feeding, and non-violent discipline. At the beginning of each visit, the home visitor reviews the activities from the previous visit; and at the end, the home visitor and caretaker identify activities to practice prior to the following next visit.

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Institutional Coordination Cuna Más is housed within the Ministry of Development and Social Inclusion (MIDIS) and operates at the central, regional and local levels. Advisory, support and technical teams within the MIDIS establish program guidelines and policies, provide technical assistance and quality assurance to regional offices, design materials and curricula, and lead operational and strategic processes. Regional offices of the program manage daycare and home visiting activities through coordination with relevant stakeholders, training and supervision of technical and community actors, and monitoring of program operations. On the local level, communities and local institutions are closely involved in decision-making, monitoring, and overall program implementation on a voluntary basis and in close coordination with government actors.

Similar to many other social policies and programs in Peru, Cuna Mas is financed through a results-based budgeting approach, in which the allocation of resources is tied to the achievement of specific targets. The Ministry of Economy and Finance (MEF) oversees the budget based on key program outputs such as the number of children and families receiving services, the number of professionals receiving training or technical assistance, and the completion of other program management, monitoring, and evaluation activities. In 2016, the total cost of the home visiting service was 129 million Soles, or approximately US$480 per family. The primary cost, which constitutes 61% of total program cost, is allocated for compensation of regional staff and community actors including the facilitadoras.

Impact Evaluation An impact evaluation of the home visiting service analyzed the association between parenting program quality and child development outcomes (Araujo et al., 2018). Based on two separate measures of child development outcomes, the evaluation found large and significant effects of the Cuna Mas home visiting program on children’s cognitive and language development outcomes, as well as significant but smaller effects on problem solving and communications skills.17 There were larger impacts on cognitive development among girls, children from poorer households, and children of low-education parents. Receptive language development was also greater among younger children, children from poorer households, and children of low-education parents.

Summary Table – Parenting AM (Peru)

Target Population



based Individual



Twice per

month

Home visits; weekly

Daycare service

‘Family life’, ‘Learning through play’, ‘Tell me a

story’

Adapted from Reach Up

Play, Feedback to Parents

Facilitadoras: Literacy, work with children;

Monthly stipend

References and key resources Araujo, M. Caridad; Dormal, Marta; Rubio-Codina, Marta. 2018. Quality of parenting programs and child development outcomes: The case of Peru’s Cuna Mas. Washington, DC: Inter-American Development Bank.

Josephson, K., Guerrero, G., and Coddington, C. 2017. Supporting the Early Childhood Workforce at Scale: The Cuna Más home visiting program in Peru. Washington, D.C.: Results for Development.

17 The Ages and Stages Questionnaires (ASQ-3) for problem solving and communication; and the Bayley Scales of Infant and Toddler Development (Bayley-III) for cognitive and receptive language. Please see Araujo et al. 2018 for more information.

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Accompanying Measures of Public Works Programs

Burkina Faso: A pioneer in mobile creche implementation at public works sites

The Youth Employment and Skills Development (YESD) project responds to the challenges of high poverty, low employment, and poor child development outcomes in Burkina Faso by increasing access to temporary employment and skills development for youth. The YESD project includes a public works component in which beneficiaries participate in labor-intensive temporary employment opportunities including for infrastructure rehabilitation and natural resources management. Young women constitute over 70 percent of participants, many of whom are pregnant or have young children. Previously, mothers were either unable to participate in the program entirely, had to leave their young children at home unsupervised or bring them along to the worksites where they were left unattended and exposed to worksite dangers. A mobile creche program was recently added on to the existing public works activities under YESD in order to provide mobile childcare at public works sites, which is expected to facilitate female project participation and improve child development outcomes. The model of mobile childcare follows women as they move between worksites and builds on existing tools, services, and the expertise of local partners to the greatest extent possible. The curriculum focuses on child stimulation using locally appropriate toys and also includes parental education to improve the socio-emotional, intellectual, sensory, and linguistic development of children.

Childcare Accompanying Measure The mobile childcare component is open to all children between the ages of 0-6 of public works participants. The primary objectives are to facilitate participation in public works activities particularly among women, create a safe environment for children to learn and develop, build positive attitudes and behaviors for beneficiary parents, and allow siblings to attend school rather than care for younger siblings. There are two models of childcare provided according to the child’s age: a mobile model for children between 3 months to 2 years, and a daycare for children aged 2-6 years. The mobile model and daycare have separate curricula customized for each age group, but both occur in the same location, whether in a daycare center, primary school, or at a flexible location close to the worksites. The mobile model aims to facilitate greater mother-child interaction and recommended breastfeeding practices and focuses on the basic needs of young children: sleep, play, and feeding. The daycare curriculum includes more complex topics that support socialization, good behavior, basic hygiene, and language and cognitive development. Activities relate to early mathematics and reading, music education, motor development activities, and free play time.

Service Delivery The mobile childcare occurs daily, every day except Sunday, from 6am to 1pm while the public works activities are being carried out. The mobile childcare sites are located in a safe, secure, clean and covered area adjacent to the public works sites. This allows parents to visit their children throughout the day and lactating mothers to continue with appropriate breastfeeding. The caretakers are women from the community known as Brigadieres Assistantes Maternelles (BAM). They receive training from instructors in early childhood development on topics such as proper and safe childcare practices as well as early stimulation for young children. Training sessions are delivered in the local language used at the worksites. The children receive one meal per day at the childcare sites, and all costs for the program are split between the beneficiary community, local service providers and the YESD project. In addition to the childcare, parents are encouraged to participate in sessions to build knowledge on improved parenting practices, which are also led by the ECD instructors.

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Institutional Coordination Coordination occurs across national government agencies and local government authorities involved in early education, early childhood development, and service provision. The primary government agencies involved in overseeing the mobile childcare program are the Directorate of Early Childhood Development within the Ministry of Women, National Solidarity and Family; and the Directorate of Preschool and Primary Education within the Ministry of National Education and Literacy. The Ministry of Health also supports the health and hygiene aspects of the program. On the local level, the program coordinates closely with local government authorities and providers of social services. The participation of municipal authorities is highlighted given their close proximity with local populations. Mayors and other local authorities are involved to reinforce the role of women in community activities, build support and financing from partners and stakeholders, and incorporate mobile childcare into regular community monitoring, budgeting, and planning processes.

Impact Evaluation An impact evaluation has not yet been conducted for the mobile creche program in Burkina Faso however a randomized control trial is in the planning stage. Early qualitative assessment of the pilot program revealed that mobile creches do help facilitate female participation in public works programs. They allow women to more fully focus on the work they are assigned, knowing that their children are cared for and safe. The mobile childcare model has been expanded to other public works sites and continued assessments are planned to determine the impact on the effectiveness of public works programs as well as early childhood outcomes.

Summary Table – Childcare AM (Burkina Faso)

Target Population



based Other

Children aged 0-6 of PW

participants; Caregivers


Mother-child interaction,

nutrition, child stimulation,

hygiene

Own; developed by education and

ECD government

agencies

Demonstration, Play, Feedback

to Parents

Brigadieres Assistantes

Maternelles (BAM); Public works


References and key resources World Bank on Social Protection in Africa: Burkina Faso Mobile Childcare Scheme Could Transform Public Works. 2019. https://cfi.co/africa/2019/01/world-bank-on-social-protection-in-africa-burkina-faso-mobile-childcare-scheme-could-transform-public-works/

Creches Mobiles/Haltes Garderies en Resume. 2019. YESD Project Document.

Le concept des creches. 2019. YESD Project Document.

https://cfi.co/africa/2019/01/world-bank-on-social-protection-in-africa-burkina-faso-mobile-childcare-scheme-could-transform-public-works/

https://cfi.co/africa/2019/01/world-bank-on-social-protection-in-africa-burkina-faso-mobile-childcare-scheme-could-transform-public-works/

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Cameroon: A mobile creche pilot with childcare provision and parental education

Cameroon is a lower-middle income country with modest economic growth; however, inequality has increased, and poverty reduction has been slow since 2001. Health and education outcomes are well below those of comparator countries, and include high maternal and under-five mortality rates, an under-five stunting rate of 30 percent, and a primary completion rate of less than 75 percent. The Safety Net Project in Cameroon aims to address low levels of human capital development and limited productive opportunities among the poorest and most vulnerable people with targeted cash transfers and public works programs. While the cash transfer component also includes accompanying measures to build human capital, a mobile childcare pilot has recently been introduced into the existing labor-intensive public works program. The mobile creche aims to facilitate the participation of mothers in public works activities while supporting human capital development and school readiness among young children. While female participation in the public works program started at 38 percent, this rate increased to 50 percent in areas with the mobile childcare pilot.

Childcare Accompanying Measure The accompanying measure consists of both the daily childcare provision as well as parental education sessions for mothers to promote early childhood development. The parental education sessions help raise awareness primarily among mothers on child hygiene, cleanliness and nutrition. Each day, caretakers or childcare facilitators carry out activities related to early stimulation and learning, feeding and nutrition, health and hygiene, and child safety and security to promote socio-emotional, cognitive and motor development. The curriculum is age-appropriate and developed for children 0-3 years old and children 3-5 years old, with separate physical spaces for each. The childcare structures are built in a clean area and equipped by the public works beneficiaries with materials supplied by the local communities and are covered to protect children from the natural elements.

Service Delivery The creche operates daily for a four- to six- hour period during the workday of public works participants. Parents are responsible for ensuring their children arrive each day in good health, hygiene, and well-nourished. Lactating mothers can visit the creche every hour of the workday to breastfeed their children. The childcare facilitators are women in good standing in their communities who are selected from among existing female participants in the public works program. Three caretakers care for and supervise the beneficiary children within each creche. Training of the selected caretakers occurs in each community and is led by a local kindergarten/preschool director with support of NGOs. Topics covered include the objectives of mobile childcare, childcare quality, child safety and security, cognitive development and early stimulation, feeding and nutrition, and daily management of the creche including cleanliness. Children undergo a routine medical examination before being accepted into the childcare program. Monitoring occurs biweekly and is led by NGO focal points with support of the manager of each public works site.

Institutional Coordination The program relies on the support of local authorities and collaboration with civil society organizations, including women’s groups. A community selection group identifies the location for the childcare structure, provides local materials for construction, and selects the individuals to be involved. Women’s associations help to raise awareness and promote participation of eligible women in the public works program. The primary groups involved in local implementation include the project management unit, municipal government, local NGOs, the caretakers (childcare facilitators), trainers, public works participants, health officials, and ministry officials for early childhood development. Each of these stakeholders is assigned specific roles and responsibilities to support functioning of the creche including construction, beneficiary selection, and childcare provision, supervision, and

59

training. ECD officials ensure that young children are cared for according to the relevant norms for their age (separated into two groups of 4 months to 3 years and 3-5 years), visit each creche once a week, and provide feedback to the childcare facilitators as necessary.

Impact Evaluation Given the project remains in the pilot stage, an impact evaluation has not yet been conducted of the mobile creche program in Cameroon. Monitoring is conducted regularly to ensure functioning and quality of the creches.

Summary Table – Childcare AM (Cameroon)

Target Population



based Other




Hygiene, nutrition, early

stimulation, child protection

Own; developed by education and

ECD government

agencies

Discussion, Play, Feedback

to Parents

Female Caretakers: Public works


References and key resources République du Cameroun – Projet Filets Sociaux. 2018. Mise en place du programme pilote des crèches temporaires dans le cadre de la mise en œuvre des THIMO dans les communes de Basheo et de Dembo.

République du Cameroun – Projet Filets Sociaux. 2017. Manuel d’implémentation des Pratiques Familiales Essentielles pour le développement de la petite enfance dans le cadre de la mise en œuvre du Projet Filets Sociaux.

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Djibouti: Integrated public works and nutrition interventions focus on participation of women Djibouti’s small economy is not well diversified and relies heavily on foreign markets, and rates of formal employment are very low. Less than one percent of this small country’s land is arable, and therefore Djibouti’s population of approximately one million people depends almost entirely on imports to meet their food needs. Health indicators remain among the lowest in the world, and one third of children ages 0-5 years are moderately or severely stunted. To address to low levels of employment and high rates of malnutrition, the Government of Djibouti recently piloted an integrated public works and nutrition intervention that focuses on engaging women in work opportunities while enhancing knowledge and behaviors surrounding key nutrition activities. Activities for the public works component includes provision of basic services (e.g. garbage collection), small artisanal projects, and light labor-intensive community works. Women are given preferential access to the public works opportunities; however, they can choose to delegate participation to a different household member. The works are designed in order to facilitate participation of women to boost their income earning potential while minimizing the potential health risks, including preferential placements for pregnant and lactating women. Therefore, a key intended outcome is to empower women as priority beneficiaries of the public works income support as well as the accompanying nutrition services.

Nutrition Accompanying Measure The integrated safety net program includes two key components: a public works program and a nutrition intervention. Household participation in the public works program is conditional on the primary caregiver attending regular nutrition promotion activities. The nutrition promotion component includes monthly group meetings with a maximum of 20 caregivers – who are nearly exclusively women – in a community-based setting for three hours. Each session consists of growth and weight monitoring by a community worker, in addition to education on nutrition, feeding practices, growth promotion, cooking sessions, and distribution of nutrition supplements. The community-based approach aims to reinforce good behaviors through positive deviance and behavior change communication during both the monthly sessions and follow-up home visits. The pilot targeted households with pregnant women and children ages 0-2 in poor urban and rural areas in Djibouti. The program mirrors the more common “cash plus” programs as the nutrition measure directly accompanies participation in public works and receipt of an income transfer. With the dual focus on women as caregivers and income earners, in addition to requiring attendance at the nutrition sessions in order to participate in public works, mothers are encouraged to use the additional income they earn to adhere to the recommended nutrition practices.

Service Delivery The nutrition interventions are designed and delivered to meet the specific needs of pregnant and lactating women and mothers with children under two. The delivery of nutrition services at the community level is subcontracted to local health staff and NGOs, who also receive training from the central level health and social development ministries charged with overall program implementation. Growth monitoring sessions are organized monthly for children under two, and children between 6 and 24 months receive micronutrient supplements. Nutrition services are provided by voluntary community workers supported by community-based facilitators. The community-based nutrition interventions are complemented by the Ministry of Health for treatment of acute malnutrition, and pregnant women are referred to health centers for prenatal care. Participants can apply for up to 50 days of public works. If any child health problems are identified during the community sessions, the family receives a follow-up home visit to provide specialized counseling services or a referral to the nearest health clinic.

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Institutional Coordination The project is primarily implemented by the Djibouti Agency for Social Development (ADDS) in coordination with the Ministry of Health and local organizations. NGOs, local health clinics, and community-based staff and facilitators play an important role in implementation at the local level. During the first year and a half of program implementation, the government focused on building cross-sector collaboration between the health and social sectors, developing the necessary tools for the program, and increasing capacity of the implementing agency and partners. Monitoring and evaluation have been essential for ensuring effective program implementation. The Government of Djibouti is also working to build a social registry for poor and vulnerable households to better integrate forms of social support and coordinate efforts across government agencies and development partners.

Impact Evaluation An impact evaluation is currently underway to determine the impact of the integrated public works and nutrition program and to inform scale-up (Brodmann et al., 2016). Initial results show that women are eager to work, and that the children of public works participants consumed more nutritious food. Rates of exclusive breastfeeding increased; however, rates of malnutrition did not change. As a result of the positive findings, the Government of Djibouti has expanded the program to additional regions of the country.

Summary Table – Nutrition AM (Djibouti)

Target Population



based Other PW participants;

pregnant women and mothers of

children under 2

Monthly; with

growth monitoring

Nutrition supplement; home visits (as needed)

Nutrition, feeding

practices, growth

promotion

Health staff and NGOs;

supported by Ministries of

Health and SP


to Parents

Community workers and

facilitators; paid at daily PW rate

References and key resources Brodmann, Stefanie; Florencia Devoto, and Emanuela Galasso. 2016. Interlinking workfare and nutrition during the first 1,000 days: a new social safety net. World Bank: Washington, D.C. (Preliminary Results)

World Bank. 2014. Developing a nutrition-based social safety net program in Djibouti. https://www.worldbank.org/en/news/feature/2014/10/28/developing-a-nutrition-based-social-safety-net-program-in-djibouti

World Bank. 2018. Piloting the first integrated child nutrition and “workfare” social program in Djibouti. https://www.worldbank.org/en/programs/sief-trust-fund/brief/piloting-the-first-integrated-child-nutrition-and-workfare-social-program-in-djibouti

https://www.worldbank.org/en/news/feature/2014/10/28/developing-a-nutrition-based-social-safety-net-program-in-djibouti

https://www.worldbank.org/en/news/feature/2014/10/28/developing-a-nutrition-based-social-safety-net-program-in-djibouti

https://www.worldbank.org/en/programs/sief-trust-fund/brief/piloting-the-first-integrated-child-nutrition-and-workfare-social-program-in-djibouti

https://www.worldbank.org/en/programs/sief-trust-fund/brief/piloting-the-first-integrated-child-nutrition-and-workfare-social-program-in-djibouti

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Madagascar: Applying ECD best practices from a cash transfer program to a public works program

Eighty percent of Madagascar’s 25 million inhabitants live in extreme poverty, and female-headed households and families with many children face the highest poverty rates. Levels of human capital remain among the lowest in the world, especially among children. The Productive Safety Net Program (PSNP) is a public works program that offers seasonal employment opportunities to poor individuals in communities vulnerable to food insecurity and climate shocks. The lack of childcare services at project sites limits female program participation and misses an opportunity to improve outcomes for children who are either brought to workplace sites with their parents or left at home unattended. A mobile creche pilot has been incorporated into the PSNP that utilizes the successful approach to early childhood development that was incorporated into the Human Development Cash Transfer (HDCT) program in Madagascar and shown to have positive impacts on child development.

Childcare Accompanying Measure The mobile creches are targeted towards children aged 0-5 of public works participants, which represents 55 percent of beneficiary households. The mobile creche curriculum focuses on intensive early childhood development through promotion of key family practices such as health, nutrition, hygiene, and child protection; as well as early stimulation through talk, play, and peer interaction. These interventions aim to support the development of children in four key areas: physical and motor, language and communication, self-development and socialization, and cognitive. The mobile creche also provides basic support and protections such as nutritional supplements, clean drinking water, protection from worksite dangers, spaces for hygiene and handwashing, improved health behaviors, positive treatment of children, and birth registration with local government. In addition to the childcare, parental education takes place both during the seasonal work cycles at the worksites and in between work cycles at community-based “spaces of well-being”. Parents play an extremely important role in the overall functioning of the creche by respecting the various rules, participating in activities, investing both time and resources in their children’s development at home and while in care, and supporting continued child development activities.

Service Delivery Children of public works participants attend childcare for five hours a day during the 40 active workdays of each working season. Mother leaders at each worksite are responsible for the care of children and facilitate the early learning and stimulation activities. They are trained by accompanying specialists (AS) in childcare facilitation, delivery of the accompanying measures, and child protection, and also monitor progress in child development. One member of the community-based Social Protection Committee (CPS) coordinates activities at each worksite and monitors the ECD activities led by the mother leaders. FID and the AS further support supervision of the childcare activities. The CPS establish the physical spaces used for childcare services. In addition to child development activities, cooking demonstrations and nutritional supplementation are provided that parents can participate in. Areas for clean restrooms and handwashing are provided and strict health controls are followed, including prohibiting the attendance of sick children. Worksite managers supervise the overall public works program and monitor basic functioning of the childcare provision on a daily basis.

Institutional Coordination Implementation of the project is led by the Social Investment Fund for Development (FID) with supervision conducted by the Ministry of Population, Social Protection, and Promotion of Women (MPPSPF). The design and implementation of the mobile creches in Madagascar also involves participation across health, nutrition, and education sectors. The Ministry of National Education (MEN) supports parental education, the development of the ECD guide, training of trainers, and monitoring of ECD activities conducted at the childcare sites. UNICEF

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supports the design, training, and technical support for the key family practices included in the childcare curriculum. The National Office of Nutrition (ONN) leads nutrition education for beneficiaries, whereas the Ministry of Health and local health centers raise awareness among beneficiaries and train facilitators on key components of public health. At the community level, coordination occurs with local health and nutrition services including the basic healthcare centers to support a healthy and safe environment for children at childcare sites.

Impact Evaluation The program remains in the pilot stage, so no impact evaluation has yet been conducted. While mobile childcare is present at five sites as of May 2019 (one in each region with the public works program), it aims to reach 260 sites in the current phase. An impact evaluation is currently underway for the overall PSNP program.

Summary Table – Childcare AM (Madagascar)

Target Population



based Other



Monthly

Childcare during PW activities; support services

Health, nutrition, hygiene, child

protection, child stimulation

UNICEF KFP with Ministry of Education and

HDCT ECD activities


to Parents

Mother Leaders selected from among public

works participants

References and key resources Fonds d’Intervention pour le Développement (FID). 2019. Manuel opérationnel pour la mise en œuvre des Mesures d’Accompagnement des Ménages du Programme ACTP pour le financement additionnel du FSS.

World Bank. 2019. Madagascar - Social Safety Net Project: Additional Financing (English). Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/619731551754900188/Madagascar-Social-Safety-Net-Project-Additional-Financing

http://documents.worldbank.org/curated/en/619731551754900188/Madagascar-Social-Safety-Net-Project-Additional-Financing

http://documents.worldbank.org/curated/en/619731551754900188/Madagascar-Social-Safety-Net-Project-Additional-Financing

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Rwanda: Introducing home-based early childhood development as a separate public works component

Despite sustained improvements in health and human development outcomes and current strong initiatives by the Government, further investments in evidence-based childhood development are needed to accelerate human capital formation in Rwanda. The country continues to struggle with high rates of stunting at 38 percent of children under 5 (as per 2014/2015 DHS data), reflecting potential delays in children’s development. The Vision 2020 Umurenge Programme (VUP) is a flagship program of the Government of Rwanda in collaboration with development partners and NGOs to eradicate extreme poverty by 2020. VUP relies on the existing system of decentralization in Rwanda and leverages technical and financial assistance to accelerate the rate of poverty reduction. The safety net component of the VUP provides short-term public works as well as medium-term flexible public works employment known as Expanded Public Works (ePW). The primary objectives of the ePW scheme are to smooth household consumption, promote graduation from poverty, and implement local development interventions while ensuring gender and child sensitivity. The ePW targets extremely poor households nationwide and includes a Home-Based ECD scheme that was launched in FY2018/19. The safety net component of VUP includes a new co-responsibility cash transfer, the Nutrition Sensitive Direct Support (NSDS), targeted to poorest households with pregnant women and/or children under 2, incentivizing them to uptake preventive health and nutrition services including antenatal care, postnatal care and growth monitoring and promotion sessions.

Childcare Accompanying Measure The ePW subcomponent of VUP includes a workstream for moderately labor-constrained household members to become providers of home-based ECD (HB-ECD) childcare services. The dual objectives of the HB-ECD are to provide employment for extremely poor households with caring responsibilities, and provide safe, accessible, and stimulating childcare for children aged 2-6 while their parents work. Parents are expected to live in close proximity to each other and children are cared for near their own homes. All sites are required to have a safe latrine, hand washing facilities, safe drinking water, nutritious meal, safe and age-appropriate play and learning equipment, and an outside play area. The lead caregiver is responsible for managing the care site to the appropriate standards. In addition to the childcare workstream, parenting education sessions occur every month for members of the childcare group but are open to all parents of young children and pregnant women in the village. The topics covered include child and maternal health and nutrition, hygiene and sanitation, cognitive and emotional development, play, child protection, parenting and responsive care, and gender equality. In addition, this SP intervention is embedded and rolled out under National ECD guidelines, provided by the National ECD Program (NECDP), under the Ministry of Gender and Family Promotion (MIGEPROF).

Service Delivery Lead and assistant caregivers are selected from among ePW beneficiaries to ensure a safe environment and provide stimulating care for participant children. They also prepare food for children, distribute food supplements to parents/guardians, facilitate necessary health, ECD, or case management referrals, and support monthly visits led by community health workers for health screening and parental education. A total of seven caregivers (one lead and six Figure 2. Tiered system of program supervision, monitoring,

and implementation. Source: ePW Guidelines, 2018.

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assistants) support up to 10-15 children on a rotating basis. HB-ECD operates year-round for up to 6 days per week. The caregivers receive the same daily rate as all public works participants, and lead caregivers receive an additional stipend for basic foodstuffs and other necessary childcare materials. Various levels of supervisors and trainers are identified within each area to build capacity in ECD, provide technical oversight, train caregivers, visit and monitor childcare settings, and lead parenting education sessions. A tiered system of supervision exists in which roles and responsibilities of parents, lead caregivers, assistant caregivers, supervisors, and higher-level officers and staff are integrated and well defined (Figure 3). For the initial stages of implementation, the Local Administrative Entities Development Agency (LODA) relies on an expert service provider to guide on training material and training curricula, aligned with national standards, to ensure an appropriate inclusion of ECD and parenting content.

Institutional Coordination Local and national government agencies share responsibility for project supervision and implementation. Overall, the VUP is led by the Ministry of Local Government (MINALOC) on policy and strategy aspects whereas operational coordination is led by the LODA with support of decentralized local entities (districts, sectors, cells and villages). Cell-level supervisors coordinate with community health workers (CHWs) to facilitate monthly health screening visits for participant children. The program of home-based parenting training and supervision for the childcare-focused ePW is developed in close coordination with the Ministry of Gender and Family Promotion (MIGEPROF) and the Ministry of Health (MOH). As aforementioned, MIGEPROF is responsible for establishing national ECD guidelines through the NECDP, which are followed by HB- ECD centers under ePW while the MOH oversees the work of CHWs.

Impact Evaluation Monitoring and evaluation of the ePW scheme is implemented by LODA, with close support and coordination with the NECDP. While no impact evaluations have yet been carried out, a process evaluation of the childcare ePW scheme will be carried out and integrated into the overall VUP evaluation strategy. Regular monitoring ensures that lessons learned are integrated into improvement of the scheme. Earlier impact evaluations of the VUP direct support (unconditional cash transfer) and classic public works scheme found some positive impacts on household well-being, however benefits of the classic public works scheme were not sustained over time.

Summary Table – Childcare AM (Rwanda)

Target Population



based Other



Monthly; open to all

Regular childcare service as

PW workstream

Health, nutrition, hygiene, parenting

practices, child stimulation, child

protection

Based on national ECD

guidelines, developed by expert service

provider

Demonstration, Play, Child Interaction,

Parent Feedback

ePW caregivers; paid at daily PW

rate

References and key resources Republic of Rwanda. 2018. Vision 2020 Umurenge Programme (VUP): Expanded Public Works Guidelines. Kigali, Rwanda: Local Administrative Entities Development Agency (LODA).

World Bank. 2017. Rwanda - Strengthening Social Protection Project (English). Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/761071513825243134/Rwanda-Strengthening-Social-Protection-Project

http://documents.worldbank.org/curated/en/761071513825243134/Rwanda-Strengthening-Social-Protection-Project

Social Protection & Jobs Discussion Paper Series Titles 2018-2020

No. Title 2007 Boosting the Benefits of Cash Transfer Programs During the Early Years: A Case Study Review of

Accompanying Measures by Laura Rawlings, Julieta Trias, and Emma Willenborg October 2020 2006 Expansion of Djibouti’s National Family Solidarity Program: Understanding Targeting Performance of

the Updated Proxy Means Test Formula by Vibhuti Mendiratta, Amr Moubarak, Gabriel Lara Ibarra, John van Dyck, and Marco Santacroce August 2020 2005 Assessing the Targeting System in Georgia: Proposed Reform Options by Maddalena Honorati, Roberto Claudio Sormani, and Ludovico Carraro July 2020 2004 Jobs at risk in Turkey: Identifying the impact of COVID-19 by Sirma Demir Şeker, Efşan Nas Özen, and Ayşenur Acar Erdoğan July 2020 2003 Assessing the Vulnerability of Armenian Temporary Labor Migrants during the COVID-19 pandemic by Maddalena Honorati, Soonhwa Yi, and Thelma Choi July 2020 2002 Getting it Right: Strengthening Gender Outcomes in South Sudan by Samantha de Silva, Abir Hasan, Aissatou Ouedraogo, and Eliana Rubiano-Matulevich July 2020 2001 The Science of Adult Literacy by Michael S. C. Thomas, Victoria C. P. Knowland, Cathy Rogers January 2020 1936 Moving forward with ALMPs: Active labor policy and the changing nature of labor markets by Jose Manuel Romero and Arvo Kuddo November 2019 1935 Unbundled: A framework for connecting safety nets and humanitarian assistance in refugee settings by Karin Seyfert, Valentina Barca, Ugo Gentilini, Manjula Luthria, and Shereen Abbady September 2019 1934 Decentralization’s effects on education and health: Evidence from Ethiopia by Jean-Paul Faguet, Qaiser Khan, and Devarakonda Priyanka Kanth September 2019 1933 Extending Pension Coverage to the Informal Sector in Africa by Melis Guven July 2019

1932 What Employers Actually Want - Skills in demand in online job vacancies in Ukraine by Noël Muller and Abla Safir May 2019 1931 Can Local Participatory Programs Enhance Public Confidence: Insights from the Local Initiatives Support

Program in Russia by Ivan Shulga, Lev Shilov, Anna Sukhova, and Peter Pojarski May 2019 1930 Social Protection in an Era of Increasing Uncertainty and Disruption: Social Risk Management 2.0 by Steen Lau Jorgensen and Paul B. Siegel May 2019 1929 Developing Coherent Pension Systems: Design Issues for Private Pension Supplements to NDC Schemes by William Price April 2019 1928 Pensions in a Globalizing World: How Do (N)DC and (N)DB Schemes Fare and Compare on Portability

and Taxation? by Bernd Genser and Robert Holzmann April 2019 1927 The Politics of NDC Pension Scheme Diffusion: Constraints and Drivers by Igor Guardiancich, R. Kent Weaver, Gustavo Demarco, and Mark C. Dorfman April 2019 1926 Setting Up a Communication Package for the Italian NDC by Tito Boeri, Maria Cozzolino, and Edoardo Di Porto April 2019 1925 Sweden’s Fifteen Years of Communication Efforts by María del Carmen Boado-Penas, Ole Settergren, Erland Ekheden, and Poontavika Naka April 2019 1924 Information and Financial Literacy for Socially Sustainable NDC Pension Schemes by Elsa Fornero, Noemi Oggero, and Riccardo Puglisi April 2019 1923 Communicating NEST Pensions for “New” DC Savers in the United Kingdom by Will Sandbrook and Ranila Ravi-Burslem April 2019 1922 Harnessing a Young Nation's Demographic Dividends through a Universal NDC Pension Scheme: A Case

Study of Tanzania by Bo Larsson, Vincent Leyaro, and Edward Palmer April 2019 1921 The Notional and the Real in China’s Pension Reforms by Bei Lu, John Piggott, and Bingwen Zheng April 2019

1920 Administrative Requirements and Prospects for Universal NDCs in Emerging Economies by Robert Palacios April 2019 1919 Bridging Partner Lifecycle Earnings and Pension Gaps by Sharing NDC Accounts by Anna Klerby, Bo Larsson, and Edward Palmer April 2019 1918 The Impact of Lifetime Events on Pensions: NDC Schemes in Poland, Italy, and Sweden and the Point

Scheme in Germany by Agnieszka Chłoń-Domińczak, Marek Góra, Irena E. Kotowska, Iga Magda, Anna Ruzik-Sierdzińska, and

Paweł Strzelecki April 2019 1917 Drivers of the Gender Gap in Pensions: Evidence from EU-SILC and the OECD Pension Model by Maciej Lis and Boele Bonthuis April 2019 1916 Gender and Family: Conceptual Overview by Nicholas Barr April 2019 1915 Labor Market Participation and Postponed Retirement in Central and Eastern Europe by Robert I. Gal and Márta Radó April 2019 1914 NDC Schemes and the Labor Market: Issues and Options by Robert Holzmann, David Robalino, and Hernan Winkler April 2019 1913 NDC Schemes and Heterogeneity in Longevity: Proposals for Redesign by Robert Holzmann, Jennifer Alonso-García, Heloise Labit-Hardy, and Andrés M. Villegas April 2019 1912 Annuities in (N)DC Pension Schemes: Design, Heterogeneity, and Estimation Issues by Edward Palmer and Yuwei Zhao de Gosson de Varennes April 2019 1911 Overview on Heterogeneity in Longevity and Pension Schemes by Ron Lee and Miguel Sanchez-Romero April 2019 1910 Chile's Solidarity Pillar: A Benchmark for Adjoining Zero Pillar with DC Schemes by Eduardo Fajnzylber April 2019 1909 Sweden: Adjoining the Guarantee Pension with NDC by Kenneth Nelson, Rense Nieuwenhuis, and Susanne Alm April 2019

1908 The ABCs of NDCs by Robert Holzmann April 2019 1907 NDC: The Generic Old-Age Pension Scheme by Marek Góra and Edward Palmer April 2019 1906 The Greek Pension Reforms: Crises and NDC Attempts Awaiting Completion by Milton Nektarios and Platon Tinios April 2019 1905 The Norwegian NDC Scheme: Balancing Risk Sharing and Redistribution by Nils Martin Stølen, Dennis Fredriksen, Erik Hernæs, and Erling Holmøy April 2019 1904 The Polish NDC Scheme: Success in the Face of Adversity by Sonia Buchholtz, Agnieszka Chłoń-Domińczak, and Marek Góra April 2019 1903 The Italian NDC Scheme: Evolution and Remaining Potholes by Sandro Gronchi, Sergio Nisticò, and Mirko Bevilacqua April 2019 1902 The Latvian NDC Scheme: Success Under a Decreasing Labor Force by Edward Palmer and Sandra Stabina April 2019 1901 The Swedish NDC Scheme: Success on Track with Room for Reflection by Edward Palmer and Bo Könberg April 2019 1803 Rapid Social Registry Assessment: Malawi’s Unified Beneficiary Registry (UBR) by Kathy Lindert, Colin Andrews, Chipo Msowoya, Boban Varghese Paul, Elijah Chirwa, and Anita Mittal November 2018 1802 Human(itarian) Capital? Lessons on Better Connecting Humanitarian Assistance and Social Protection by Ugo Gentilini, Sarah Laughton and Clare O’Brien November 2018 1801 Delivering Social Protection in the Midst of Conflict and Crisis: The Case of Yemen by Afrah Alawi Al-Ahmadi and Samantha de Silva July 2018 To view Social Protection & Jobs Discussion Papers published prior to 2018, please visit www.worldbank.org/sp.

ABSTRACTUsing a case study approach, this comparative review examines the operational arrangements of child-focused accompanying measures in nutrition and parenting from 19 cash transfer programs. It covers both family-focused cash transfer programs for households with children, and public works programs that have incorporated accompanying measures largely in response to the need for childcare among beneficiaries. The accompanying measures reviewed include: incentives for pregnant women, parents and caregivers to use available supply-side services; the direct provision of child focused goods and services as part of the cash transfer program; and behavioral interventions for parents and caregivers to build knowledge and inform choices and parenting practices. As context for the operational case study approach, the note includes a theory of change and brief review of the available evidence on cash transfer programs’ impact on young children’s development. The note also provides a set of operational lessons learned and a ‘forward look’ to inform program design and future research.

ABOUT THIS SERIES Social Protection & Jobs Discussion Papers are published to communicate the results of The World Bank’s work to the development community with the least possible delay. This paper therefore has not been prepared in accordance with the procedures appropriate for formally edited texts.

For more information, please contact the Social Protection Advisory Service via e-mail: [email protected] or visit us on-line at www.worldbank.org/sp